MASSACHUSETTS  • 
•HISTORICAL-SOCIETY 


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of  the 
American  Bed  Cross 


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TYPHUS  FEVER 

WITH  PARTICULAR  REFERENCE 

TO  THE  SERBIAN  EPIDEMIC 


BY 


RICHARD  P.  STRONG,  M.D.,  S.D. 

DIRECTOR  OF  THE  AMERICAN  BED  CROSS  AND  INTERNATIONAL  SANITARY  COMMISSIONS  TO  SERBIA 
PROFESSOR  OF  TROPICAL  MEDICINE,  HARVARD  UNIVERSITY  MEDICAL  SCHOOL 


GEORGE  C.  SHATTUCK,  A.M.,  M.D.   A.  W.  SELLARDS,  A.M.,  M.D. 


MEMBER  OP  THE  AMERICAN  RED  CROSS  SANITARY 

COMMISSION  TO  SERBIA 

GENERAL  MEDICAL  SECRETARY,  LEAGUE  OF 

RED  CROSS  SOCIETIES 


MEMBER  OP  THE  AMERICAN  RED  CROSS  SANITARY 

COMMISSION  TO  SERBIA 

ASSISTANT  PROFESSOR  OP  TROPICAL  MEDICINE 

HARVARD  UNIVERSITY  MEDICAL  SCHOOL 


HANS  ZINSSER,  M.D. 

BACTERIOLOGIST  OF  THE  AMERICAN  RED  CROSS 

SANITARY  COMMISSION  TO  SERBIA 

PROFESSOR  OF  BACTERIOLOGY,  COLUMBIA  UNIVERSITT 


J.  GARDNER  HOPKINS,  M.D. 

BACTERIOLOGIST  OF  THE  AMERICAN  RED  CROSS 
SANITARY  COMMISSION  TO  SERBIA 


PUBLISHED  BY  THE  AMERICAN  RED  CROSS 

AT  THE 

HARVARD  UNIVERSITY  PRESS 
CAMBRIDGE,  MASS. 
1920 


/?  C.  /  <?  ? 


COPYEIGHT,  1921 
HARVABD  UNIVERSITY  PRESS 


^27553 


JOl  5     1962 


BOSiiiON  COLLEGE  LIBRARY 
CHESTNUT  HILL,  MA^ 


TABLE  OF  CONTENTS 

PART  I 

TYPHUS  FEVER  WITH  PARTICULAR  REFERENCE 
TO  THE  SERBIAN  EPIDEMIC 

BY 

RICHARD  P.  STRONG 


PAGE 


Typhus  Fever  with  Particular  Reference  to  the  Serbian  Epi- 
demic   3 

Conditions  in  Serbia  Relating  to  Epidemic 4 

Origin  of  Epidemic 18 

Organization 20 

Preventive  Measures 23 

Summary  of  Previous  Epidemics 38 

Method  of  Transmission 42 

Aetiology 49 

The  Significance  of  Rickettsia  in  Relation  to  Disease  ...  51 

Weil-Felix  Reaction 86 

Bacteriological  Studies  in  Serbia      86 

Course  of  Serbian  Epidemic 87 

Acknowledgments 90 

End  of  Epidemic 93 

The  Polish  Epidemic  of  Typhus,  1916 93 

Russia  as  an  Endemic  Center  of  Typhus 94 

The  Present  Polish  Epidemic 94 

Action  by  the  League  of  Red  Cross  Societies 98 

Response  to  Appeal  of  League  of  Red  Cross  Societies     .    .  103 

Further  Need  of  Personnel  and  Supplies 104 

Importance  of  Further  Administrative  Measures  in  Com- 
bating the  Epidemic 105 

iii 


iv  TABLE  OF  CONTENTS 

PART  II 

CLINICAL  OBSERVATIONS  ON  TYPHUS  FEVER 
IN  SERBIA  IN  1915 

BY 

GEORGE  C.  SHATTUCK 

PAGE 

Prefatory  Note     .    .' Ill 

Literature  on  Typhus 112 

Usual  Course  of  the  Disease ,    .    .,114 

Material  and  Plan  of  Work 115 

Observations 

I.    Fever 116 

IL    The  Skin   . 118 

III.  Circulatory  Signs  and  Symptoms 124 

IV.  Pathology  of  the  Circulatory  System 131 

V.    Blood 136 

VI.    Respiratory  Signs  and  Symptoms 138 

VII.    Pathology  of  the  Respiratory  System 141 

VIII.    Digestive  System:  Signs  and  Symptoms. 142 

IX.    Pathology  of  the  Digestive  System 145 

X.    The  Nervous  System:  Signs  and  Symptoms  ......  146 

XL    Pathology  of  the  Nervous  System 149 

■  XII.    Genito-Urinary  System 152 

XIII.  Bones  and  Muscles 153 

XIV.  Organs  of  Special  Sense 153 

XV.    Complications  and  Sequelae 154 

XVI.    Convalescence 160 

XVII.    Diagnosis 160 

XVIII.    Treatment  in  General 165 

XIX.    Symptomatic  Treatment 172 

Appendix 

Case  Groups  (a)  Typhus  Fever:  Recovery 177 

(b)  Typhus  Fever:  Fatal  —  With  Autopsy    .  208 

(c)  Typhus  Fever:  Fatal  —  No  Autopsy    .    .  232 

(d)  Problems  in  Diagnosis 235 


TABLE  OF  CONTENTS  v 

PART  III 

LABORATORY  EXAMINATIONS  IN 
TYPHUS  FEVER 

BY 

ANDREW  WATSON  SELLARDS 

PAGE 

Introduction 243 

Examination  of  the  Blood  in  Typhus  Fever 244 

Red  Blood-Cells 244 

White  Blood-Cells 245 

Examination  of  the  Urine 249 

Differential  Diagnosis 249 

Bacteriological  Cultures  in  Typhus  Fever 250 

Animal  Experimentation 253 

Question  OF  the  Mode  OF  Transmission  OF  Typhus  Fever  .    .    .         256 
Experimental   Transmission   of   Typhus   to   Monkeys   by   the 
Body  Louse 257 


PART  IV 

REPORT  OF  BACTERIOLOGIST  OF  THE 

AMERICAN  RED  CROSS  SANITARY 

COMMISSION  TO  SERBIA 

BY 

HANS  ZINSSER 

Establishment  of  Laboratory 261 

Bacteriological  Examinations . 263 

Vaccination 267 


VI  TABLE  OF  CONTENTS 

PART  V 

SUPPLEMENTARY  BACTERIOLOGICAL  REPORT  OF 

THE  AMERICAN  RED  CROSS  SANITARY 

COMMISSION  TO  SERBIA 

BY 

J.  GARDNER  HOPKINS 

PAGE 

Blood  Culture  Studies 269 

Agglutination  Studies 271 

Autopsies 272 

Guinea  Pig  Inoculations 272 

Later  Cases 272 

Results  .    ,    ,    '. 272 


LIST  OF  ILLUSTRATIONS 

PLATE  PACING  PAGE 

I.  American  Red  Cross  Hospital  at  Ghevgheli    ........       8 

II.  Fig.  1.   Black  flags  indicating  deaths  prom  typhus  within  the 

HOUSES. 

Fig.  2.   Typhus  victims  awaiting  burial  {Photo  by  Miss  Tetrault)    20 

III.  Fig.  1.   Camp  of  unit  of  American  Red  Cross  Sanitary  Commis- 

sion. 
Fig.  2.   Professor  Zinsser  and  Dr.  Maitland  at  the  Paget 

TYPHUS  hospital 22 

IV.  Fig.  1.   Type  of  motor  truck  most  successfully  employed. 

Fig.  2.   Disinfection  of  carriages 24 

V.  Fig.  1.   Evacuation  of  badly  infected  district  prior  to  its  de- 

struction BY  BURNING. 
Fig.  2.   The  usual  method  of  transportation  in  Serbia   ...     26 

VI.  Figs.  1  and  2.    Refugees  for  disinfestation 26 

VII.  Fig.  1.   Women  and  children  about  to  be  bathed  and  disin- 

fected. 
Fig.  2.  Austrian  prisoners  about  to  be  deloused 28 

VIII.  Figs.  1  and  2.    Refugee  women  and  children,  and  men  after 

BATHING  AND   DISINFESTATION 28 

IX.  Fig.  1.   Refugee  camp. 

Fig.  2.   Austrian  prisoners  after  being  bathed  and  disinfested    28 

X.  Detachment  of  Serbian  army  after  disinfestation  and  vacci- 

nation  ,     30 

XI.  Figs.  1  and  2.    Disinfecting  unit  in  charge  of  Dr.  F.  Gruver    30 

XII.  Fig.  1.   Steam  bathing  and  disinfesting  unit  in  charge  of  Dr. 

T.  W.  Jackson. 
Fig.  2.   Men  leaving  tent  before  bathing 32 

XIII.  Fig.  1.   Leaving  bath. 

Fig.  2.  Returning  to  dressing  tent      32 

XIV.  Fig.  1.   Construction  of  delousing  plant  with  Austrian  prison 

LABOR. 

Fig.  2.   Bathing  and  disinfesting  unit  in  charge  of  Dr.  George 

C.  Shattuck 32 

XV.  Bathing  and  disinfesting  unit  in  charge  of  Dr.  George  C. 

Shattuck 32 

vii 


viii  LIST  OF  ILLUSTRATIONS 

PLATE  FACING  PAGE 

XVI.  Figs.  1  and  2.    Preparation  and  disinfection  of  hospital  wards; 

UNIT   IN   CHARGE    OF   Dr.  FrANCIS   B.  GrINNELL 34 

XVII.  Fig.  1.   Typhus  ward  after  cleaning  and  disinfecting. 

Fig.  2.  Antimalarial  section  at  work  in  Macedonia     ....     34 

XVIII.  Vaccination  against  cholera,  typhoid,  and  paratyphoid  fevers 

BY  Professor  Castellani's  method 38 

XIX.  Troops  being  vaccinated  after  disinfestation  by  train  unit  in 

CHARGE    OF   MaJOR   EdWARD    StuART 38 

XX.  Fig.  1.   Filled  cesspool. 

Fig.  2.  A  typical  Serbian  town  after  eradication  of  typhus  .     38 

XXI.  Figs.  1  and  2.    Rickettsia  bodies  in  the  excrement  op  normal 

lice      80 

XXII.  Figs.  1  and  2.    Temperature  charts  of  two  cases  of  experi- 

mentally PRODUCED  TRENCH   FEVER     84 

XXIII.  Chart  showing  decrease  in  fever  cases,  typhus,  relapsing, 

AND    TYPHOID    AMONG    THE    CIVILIAN    POPULATION,    MaY    TO 

August,  1915 90 

XXIV.  Sir  Thomas  Lipton  on  board  the  "Erin" 92 

XXV.  Dr.  Edward  Ryan  convalescing  from  typhus  fever  and  Miss 

Gladwin,  chief  nurse,  A.  R.  C 92 

XXVI.  Photographic  illustrations  of  cases  at  Lady  Paget  Hospital. 
Fig.  1.   Double  parotitis. 

Fig.  2.   Three   cases    of   slight  gangrene    following  typhus 

FEVER. 

Fig.  3.   Gangrene  after  typhus '  .    .    .   156 


TYPHUS  FEVER 

WITH  PARTICULAR  REFERENCE 

TO  THE  SERBIAN  EPIDEMIC 


PART  I» 

TYPHUS  FEVER  WITH  PARTICULAR  REFERENCE 
TO  THE  SERBIAN  EPIDEMIC 

By  RICHARD   P.  STRONG 

The  epidemic  of  typhus  which  occurred  in  Serbia  in  1915  was 
one  of  the  most  severe  which  the  world  has  known  in  modern 
times.  It  not  only  interrupted  and  suspended  for  approxi- 
mately six  months  all  important  military  activities  of  the 
Serbian  army,  but  it  also  delayed  the  military  advance  of  the 
central  powers  against  that  country  during  this  period.  The 
epidemic  was  moreover  particularly  characterized  not  only  by 
its  magnitude,  but  by  its  high  virulence  and  high  mortality. 
During  the  height  of  the  epidemic  the  number  of  new  fever 
cases  entering  the  military  hospitals  alone  reached  as  high  as 
2500  per  day,  and  the  number  of  reported  cases  among  the 
civihan  population  was  approximately  three  times  this  number. 
How  many  more  unreported  cases  actually  occurred,  one  will 
never  know.  The  mortality  during  the  epidemic  varied  at  dif- 
ferent periods  in  different  localities  between  30  and  60  per  cent, 
and  in  complicated  cases  sometimes  reached  70  per  cent.  Over 
150,000  deaths  occurred  within  six  months  before  the  epidemic 
could  be  suppressed.  Coincident  with  the  epidemic  of  typhus 
there  occurred  an  epidemic  of  relapsing  fever,  and  there  was 
present  much  typhoid  fever.  Under  the  conditions  existing  at 
the  time  in  Serbia,  often  little  discrimination  in  the  diagnosis  of 
the  nature  of  the  fever  could  be  made,  and  most  cases  of  fever 
occurring  in  the  army  were  sent  or  found  their  way  to  the  mili- 
tary hospitals  which  were  practically  all  used  for  typhus  cases 
during  one  period  of  the  epidemic.  These  individuals,  if  they 
actually  did  not  have  typhus  on  entering  a  hospital,  were,  in  the 
early  stages  of  the  epidemic  at  least,  very  liable  to  contract  the 
disease.  The  figures  of  fever  cases  which  I  have  given  therefore 

3 


4  TYPHUS  FEVER 

include  the  cases  of  relapsing  fever  and  of  mixed  infection  with 
typhus  and  this  disease,  as  well  as  a  number  of  cases  of  typhoid. 
It  has  not  been  practicable  for  the  writer,  particularly  on  ac- 
count of  almost  continuous  foreign  service  during  and  in  con- 
nection with  the  war,  to  publish  before  an  extended  account  of 
the  activities  of  the  American  Red  Cross  in  connection  with  the 
suppression  of  the  typhus  epidemic  in  Serbia.  Even  today 
much  statistical  material  collected  in  Serbia  in  connection  with 
the  epidemic  is  not  at  hand  for  inclusion  in  the  report.  How- 
ever, on  account  of  the  very  wide  prevalence  at  the  present 
time  of  typhus  fever  in  epidemic  form  in  Eastern  and  Central 
Europe,  and  of  many  problems  to  be  met  in  relation  to  the  erad- 
ication of  these  epidemics,  it  has  been  considered  advisable  to 
summarize  the  Serbian  experience  and  to  publish  without 
further  delay  the  report  in  its  present  form. 

Conditions  in  Serbia  Relating  to  the  Epidemic 

It  will  be  recalled  that  before  Serbia  had  time  to  recuperate 
from  the  Turkish  and  Bulgarian  wars  of  1912  and  1913,  she  was 
plunged  into  the  third  and  greatest  world  war  in  1914,  which 
obviously  taxed  to  the  utmost  all  her  resources.  The  previous 
wars  she  had  undergone,  accompanied  by  outbreaks  of  disease, 
notably  of  cholera  in  1913,  had  already  considerably  reduced 
her  available  medical  personnel  and  her  hospital  and  sanitary 
supplies.  Serbia  thus  war-worn  and  weakened,  with  her  re- 
sources already  greatly  overburdened,  was  in  no  position  to 
combat  such  an  epidemic  as  that  with  which  she  was  confronted 
in  1915,  and  when  this  outbreak  of  disease  was  well  started  it 
spread  almost  unrestrictedly  throughout  the  land.  There  were 
only  approximately  350  Serbian  doctors  in  the  country  prior  to 
the  outbreak,  and  these  bravely  took  up  the  fight  against  ty- 
phus in  1915,  but  their  number  grew  less  day  by  day,  and  the 
steady  increase  of  the  disease  and  the  uninterrupted  strain  to 
which  they  were  submitted  by  their  military  duties,  as  well  as 
by  the  superimposed  epidemic,  finally  brought  them  to  ac- 
knowledge the  futility  of  continuing  the  attack  upon  such  a  foe 
unaided.   Indeed,  the  majority  of  the  small  number  of  Serbian 


THE   SERBIAN  EPIDEMIC  5 

doctors  sooner  or  later  became  afflicted  with  the  disease,  126  of 
them  succumbing  to  it,  a  mortaUty  of  36  per  cent.  I  recall,  very 
shortly  after  reaching  Serbia,  visiting  one  of  the  first  hospitals 
I  saw  where  I  found  six  of  the  seven  Serbian  doctors  sick  with 
typhus.  Of  the  thirteen  physicians  in  the  hospital  at  Pirot, 
twelve  contracted  the  disease  and  six  died  of  it.  Indeed  it  was 
not  an  unusual  thing  to  find  one  or  more  doctors  in  the  differ- 
ent hospitals  sick  with  the  disease.  In  an  institution  originally 
reserved  for  surgical  cases  with  400  beds,  there  were  approxi- 
mately 1600  patients,  1100  of  which  were  suffering  from  typhus. 
This  hospital  had  formerly  a  staff  of  42,  including  doctors 
and  their  assistants  and  nurses,  and  only  three  of  this  number 
remained  who  were  free  from  the  disease.  Those  physicians 
who' remained  well  were  busily  occupied  with  treating  the  sick 
or  the  wounded  from  the  battlefields,  and  general  methods  for 
prevention  throughout  the  country  were  impracticable  or  were 
not  undertaken.  There  were  obviously  not  enough  hospitals  in 
which  the  sick  could  be  properly  cared  for  or  even  properly 
sheltered.  Under  such  conditions,  with  no  efficient  sanitary 
personnel  or  sanitary  regulations,  wounded  soldiers  or  those 
affected  with  minor  diseases  or  relapsing  fever  wandered  into 
the  hospitals  whenever  they  were  so  inclined  and  entered  the 
wards  filled  with  typhus  cases,  frequently  occupying  the  same 
beds  with  them.  Indeed,  it  was  exceptional  in  most  of  the 
hospitals  to  find  only  one  patient  in  a  bed,  usually  there  were 
two  or  three  patients  in  the  same  bed  and  the  available  floor 
space  was  also  covered  with  patients  without  beds;  sometimes 
lying  upon  straw,  on  blankets,  or  closely  huddled  side  by  side 
on  the  wooden  flooring,  often  even  under  the  beds.  The  condi- 
tions in  many  of  these  hospitals  were  about  as  bad  as  they  well 
could  be.  There  were  no  lavatory  or  bathing  or  toilet  facilities 
for  the  patients,  no  clean  linen  or  clothing  for  them,  and  no 
systematic  disinfection  of  such  linen  or  the  beds.  There  were 
usually  no  nurses,  and  often  only  a  few  Austrian  prisoners 
as  attendants.  Worst  of  all,  during  the  height  of  the  epidemic 
many  of  the  patients  in  the  hospitals  received  no  care  or  atten- 
tion whatever,  for  the  reason  that  there  was  no  one  at  hand  to 


6  TYPHUS  FEVER 

render  it.  As  the  severe  type  of  the  disease  prevailed  with  de- 
lirium lasting  several  days,  it  was  sometimes  impossible  for 
patients,  particularly  those  in  the  wards  upon  the  second  floor, 
to  visit  the  latrines  outside  the  hospital.  Under  such  conditions 
the  mortality  was  naturally  great,  and  reached  in  some  in- 
stances as  high  as  70  per  cent.  In  certain  hospitals  where  pa- 
tients had  removed  their  clothing  upon  entrance,  I  have  seen 
many  piles  of  such  clothing  lying  in  the  entrance  room  with 
thousands  of  living  lice  and  ova  upon  the  garments  not  yet  dis- 
infested.  Indeed  many  hospitals  were  without  apparatus  for 
sterilizing  or  disinfesting,  or  possessed  only  unsatisfactory  ap- 
pliances for  this,  and  patients  came,  and  left  if  they  recovered, 
without  their  clothes  being  washed  or  disinfested.  In  a  few 
hospitals  the  conditions  were  so  bad  that  the  dead  lay  unburied 
for  days  at  a  time.  The  conditions  in  the  prison  camps  were 
often  worse;  the  buildings  used  as  prisons  were  almost  invari- 
ably greatly  overcrowded  and  insufficiently  ventilated.  The 
prisoners  were  frequently  confined  in  stables  also  with  very 
poor  ventilation.  In  these  there  were  no  wooden  floors  and 
they  were  compelled  to  lie  upon  the  ground  or  upon  straw 
sacks  or  loose  straw.  The  latrines  were  usually  filled  to  over- 
flowing and  in  a  most  unsanitary  condition.  Inmates  of  these 
prison  camps  I  always  found  very  lousy  on  first  inspection. 
These  camps  were  very  dangerous  to  inspect,  and  during  the 
war  many  cases  of  typhus  were  undoubtedly  contracted  in  con- 
nection with  work  in  the  various  prison  camps.^  In  Serbia  they 
proved  to  be  veritable  death  traps.  It  was  necessary  to  insti- 
tute rigid  sanitary  reforms  in  almost  every  one  of  these  prisons 
before  the  disease  could  be  eradicated.    Over  one-half  of  the 

1  Low,  The  Ann.  Report,  Local  Government  Board,  1914-15  (xliv)  gives  a  list  of  six- 
teen prison  camps  in  Germany  in  which  typhus  broke  out  in  1915,  in  ten  of  which  British 
soldiers  were  confined.  "In  the  camp  at  Langensalza,  in  April,  1915,  nearly  the  whole 
of  the  1000  prisoners  contracted  typhus  (Leonetti).  It  is  said  that  on  an  average  thirty- 
five  men  died  daily.  They  were  ill-attended,  without  medicines,  and  their  clothing  was 
insufficiently  disinfected.  In  the  camp  at  Niederzweren  typhus  also  made  serious  rav- 
ages. It  was  only  when  the  epidemic  attacked  the  civil  population  and  the  garrison  that 
precautions  were  finally  taken.  At  Erfurt  there  were  600  cases  among  20,000  prisoners. 
In  the  camp  at  Gustrow  the  hygienic  conditions  were  equally  deplorable.  The  12,000 
prisoners,  suffering  from  cold  and  hunger,  were  crowded  together  on  mouldy  straw,  with 
a  single  blanket  apiece,  which  was  worn,  and  often  torn." 


THE  SERBIAN  EPIDEMIC  7 

70,000  Austrian  prisoners  in  Serbia  died  of  typhus  during  the 
epidemic.  The  Serbians  supplied  their  prisoners  with  as  good 
food  as  it  was  possible  for  them  to  furnish,  but  the  sanitary 
conditions  of  the  people  of  Serbia  in  general  precluded  the  plac- 
ing of  their  prisoners  under  proper  sanitary  conditions. 

In  the  early  part  of  the  epidemic,  there  were  no  hospitals  for 
the  women  and  children,  so  that  when  they  were  affected  with 
the  disease  they  were  compelled  to  remain  at  home  or  wherever 
they  were  taken  sick,  and  hence  usually  were  not  attended  by 
physicians.  Nevertheless,  the  mortality  among  them  was  fre- 
quently lower  because  they  at  least  received  some  care  and  at- 
tention from  members  of  their  family  and  were  probably 
usually  fed  more  or  less  regularly. 

In  order  that  the  reader  may  better  realize  the  conditions  in 
Serbia,  a  few  extracts  from  reports  of  those  who  witnessed  these 
scenes  will  be  quoted.  Sir  Thomas  Lipton  who  did  so  much  for 
the  Serbian  people,  and  whose  own  health  was  greatly  impaired 
for  a  number  of  months  owing  to  hardship  and  exposure  under- 
gone in  Serbia  during  the  epidemic,  recounting  the  conditions 
there  in  March,  1915  says: 

''I  met  on  the  country  roads  many  victims  too  weak  to 
crawl  to  a  hospital.  Bullock-carts  were  gathering  them  up. 
Often  a  woman  and  her  children  were  leading  the  bullocks, 
while  in  the  cart  the  husband  and  father  was  raving  with  fever. 
Scarcely  enough  people  remain  unstricken  to  dig  graves  for  the 
dead,  whose  bodies  lie  exposed  in  the  cemeteries.  The  situation 
is  entirely  beyond  the  control  of  the  present  force,  which  im- 
peratively needs  all  the  help  it  can  get  —  tents,  hospitals, 
doctors,  nurses,  modern  appliances,  and  clothing  to  replace  the 
garments  full  of  typhus-bearing  vermin." 

His  picture  of  the  hospital  at  Ghevgheli,  where  Dr.  James  F. 
Donnelly  of  the  American  Red  Cross  died,  is  appalling.  Sir 
Thomas  calls  Dr.  Donnelly  one  of  the  greatest  heroes  of  the 
war.    In  his  description  of  this  hospital  he  says : 

''The  place  is  a  village  in  a  barren,  uncultivated  country,  the 
hospital  an  old  tobacco  factory,  formerly  belonging  to  Abdul 
Hamid.  In  it  were  crowded  1400  persons,  without  blankets  or 


8  TYPHUS  FEVER 

mattresses,  or  even  straw;  men  lying  in  the  clothes  in  which 
they  had  lived  in  the  trenches  for  months,  clothes  swarming 
with  vermin,  victims  of  different  diseases  —  typhus,  typhoid, 
dysentery,  and  smallpox  —  were  herded  together.  In  such  a 
state  Dr.  Donnelly  found  the  hospital,  where  he  had  a  force  of 
six  American  doctors,  twelve  American  nurses,  and  three  Ser- 
bian doctors.  When  I  visited  the  hospital  three  of  the  American 
doctors,  the  three  Serbian  doctors,  and  nine  of  the  nurses  were 
themselves  ill.  The  patients  were  waited  on  by  Austrian  pris- 
oners. The  fumes  of  illness  were  unbearable.  The  patients 
objected  to  the  windows  being  opened,  and  Dr.  Donnelly  was 
forced  to  break  the  panes.  One  of  the  first  things  he  did  on  his 
arrival  was  to  test  the  water  which  he  found  infected.  He  then 
improvised  boilers  of  oil  drums  in  which  to  boil  water  for  use, 
and  he  built  ovens  in  which  to  bake  the  clothes  of  the  patients, 
since  the  hospital  was  not  provided  with  proper  sterilizing  ap- 
paratus. The  street  cleaning  and  hospital  waiting  was  done  by 
Austrians  whose  numbers  were  rapidly  thinning  from  typhus 
and  other  diseases." 

Captain  Bennett  of  the  British  Red  Cross  in  describing  one  of 
the  prison  camps  in  Serbia  writes: 

''It  is  not  a  hospital,  remember,  but  simply  an  area  where 
750  Austrians  have  been  collected;  nevertheless  the  disease  has 
fallen  like  a  blight  upon  the  camp.  At  an  earlier  date  one  doc- 
tor was  in  charge  of  this  camp,  but  he  is  now  stricken  down  by 
typhus,  and  various  forms  of  infection  of  the  malady  are  raging 
unchecked.  Typhus,  dysentery,  smallpox,  and  diphtheria 
have  swept  over  the  place  with  devastating  effects.  Last  week 
only  twenty  men  out  of  750  could  stand  on  their  feet.  There 
they  lie  in  utter  wretchedness.  Here  and  there  one  finds  a  mat- 
tress and  here  and  there  a  little  straw,  but  the  bulk  of  the  sick 
men  are  stretched  out  on  the  muddy  ground.  Their  clothes  are 
foul  and  alive  with  vermin  which  spread  the  deadly  typhus. 
The  silence  of  the  camp  is  broken  only  by  sighs  and  groans.  A 
recent  visitor  noticed  a  number  of, recumbent  forms  covered 
with  greatcoats  and  found  on  removing  these  that  five  out  of 
the  number  had  already  been  dead  several  days.    There  was 


American  Red  Cross  Hospital  at  Ghevgheli 
PLATE  I 


THE  SERBIAN  EPIDEMIC  9 

nobody  to  remove  the  corpses.  Here  and  there  some  poor 
wretch  crawled  about  on  his  hands  and  knees  to  fetch  a  cup  of 
water  for  his  prostrate  comrade.  This  was  all  the  attendance 
which  was  visible,  and  the  shocking  condition  of  the  men  and  of 
the  ground  on  which  they  lie  can  be  imagined.  Can  any  one  be 
surprised  to  learn  that  some  sixty  men  die  in  this  camp  every 
day?  Every  man  in  this  hideous  environment  and  all  his  com- 
rades who  will  enter  it  subsequently  are  practically  appointed 
to  die,  unless  help  comes  speedily.  Uskub  is  a  veritable  valley 
of  the  shadow  of  death.  If  the  tired  nurses  leave  the  crowded 
hospitals  for  a  little  exercise  and  fresh  air  they  are  met  by  a 
long  procession  of  bullock  wagons  carrying  rude  coffins  to  the 
cemetery.  Sometimes  three  coffins  with  unfastened  lids  rest  on 
the  same  cart  and  the  bodies  of  the  dead  are  exposed  as  the 
wheels  jolt  over  the  rough  pavements." 

With  reference  to  one  of  the  hospitals  he  writes: 

^'  It  is  practically  impossible  to  go  near  it;  so  overpowering  is 
the  stench  in  the  street  outside  that  nobody  who  is  not  com- 
pelled to  approach  the  building  can  bear  to  be  in  its  vicinity. 
Details  of  the  interior  cannot  well  be  printed." 

Dr.  Lilian  Mary  Chesney  ^  points  out  that  at  the  time  when 
she  reached  Serbia  the  medical  organization  there  was  more  or 
less  paralyzed  by  the  magnitude  of  the  task,  and  cases  of  ty- 
phus were  not  separated  from  others.  A  separation  was  ef- 
fected in  about  a  week,  the  typhus  patients  alone  remaining  in 
her  hospital.  "The  hospital  itself  was  soon  much  improved  in 
condition.  The  great  difficulty  was  the  sanitary  arrangements, 
cesspools  sometimes  within  the  building  and  sealed  up  when  full 
being  in  use.  The  whole  building  was  pervaded  by  the  smell 
of  overflowing  cesspools.  The  cesspools  also  overflowed  outside 
into  the  laundry,  which  was  not  a  very  desirable  arrangement, 
but  it  did  not  seem  to  disturb  the  mind  of  the  director  at  all. 
Coffins  were  mere  open  shells  and  used  repeatedly,  the  bodies 
being  tilted  out  into  the  pits  on  reaching  the  cemetery." 

Dr.  Ethan  Butler,  who  was  Director  of  American  Red  Cross 
Serbian  Unit  No.  3,  in  writing  of  the  evidence  leading  up  to  the 

1  Chesney,  L.  M.:  Practitioner,  1916,  xcvi,  542. 


10  TYPHUS  FEVER 

illness  and  death  from  typhus  of  Dr.  Ernest  P.  Magruder  on 
April  8,  1915,  gives  an  interesting  account  of  the  conditions  he 
encountered.  Dr.  Magruder  was  one  of  the  five  American 
physicians  to  lay  down  their  lives  in  Serbia  during  the  epi- 
demic, the  others  being  Drs.  Albert  S.  Cooke,  John  M.  Kara, 
James  Francis  Donnelly,  and  Leon  Weiss.  Dr.  Butler,  describ- 
ing his  hospital,  says: 

"Only  by  stretch  of  imagination  could  it  be  called  a  hospital. 
As  a  matter  of  fact  there  was  only  one  hospital,  worthy  of  the 
name,  in  all  Serbia,  the  Military  Hospital  at  Belgrade.  Into 
this  factory,  capable  of  holding  no  more  than  750  patients  on  a 
rational  apportionment  of  floor  space,  had  been  huddled  1300 
wretched  beings,  in  filth  indescribable.  The  majority  of  these 
were  suffering  from  badly  infected  compound  fractures,  the 
result  of  shrapnel.  By  actual  count  there  were  192  beds,  many 
of  which  required  propping  up  to  keep  them  on  their  legs.  Of 
mattresses,  blankets,  sheets,  there  were  too  few.  A  little  corner 
of  the  basement,  about  25  feet  square,  filled  chiefly  by  stair- 
ways, was  serving  as  laundry,  presided  over  by  six  very  dirty 
peasant  women.  Needless  to  say,  it  was  inadequate  to  meet  the 
demands  made  upon  it.  In  another  part  of  the  basement  was  a 
huge  pile  of  exceedingly  filthy  clothes  from  the  wards  above, 
and  next  this  were  stacked  the  supplies  of  food  to  be  served 
later  to  patients  and  staff,  after  passage  through  the  squalid 
little  shed  that  was  called  a  kitchen.  Water  came  from  shallow 
surface  wells.  It  was  turbid  and  smelled  and  tasted  badly. 
Subsequent  examination  showed  evidence  of  sewage  pollution 
in  several  of  these  wells.  Excreta,  sputum,  and  pus-soaked 
dressing  were  scattered  everywhere  within  and  without  the 
building.  Vermin,  especially  the  body  louse,  were  omnipresent. 
The  stench  of  the  whole  thing  was  overwhelming.  Typhus  was 
present  in  sporadic  cases  even  when  we  arrived  and  caused 
some  anxiety,  but  it  was  fully  a  month  before  the  great  epi- 
demic that  overwhelmed  Serbia  broke  out.  Our  units  were 
hard  hit.  Of  the  twelve  nurses,  nine  had  contracted  the  dis- 
ease prior  to  the  end  of  February:  all  recovered.  Of  the  six  sur- 
geons, four  had  become  infected,  and  of  these  one.  Dr.  James  F. 


THE  SERBIAN  EPIDEMIC  11 

Donnelly,  had  died.  Dr.  Magruder  and  myself  had  escaped 
typhus.  Dr.  Magruder  was  unremitting  in  his  share  of  the 
care  of  the  staff  individuals,  nor  did  he  spare  any  efforts  re- 
gardless of  the  amount  of  the  exposure  incurred  thereby." 

Later,  Dr.  Magruder,  worn  out  by  overwork,  finally  con- 
tracted the  disease  and  died  on  April  8.  He  felt  that  he  was 
unable  to  relinquish  his  duties  and  did  not  go  to  bed  until  he 
had  been  ill  for  five  days.  As  Dr.  Butler  has  said  of  him,  ^'He 
passed  out  honorably  fulfilling  the  trust  imposed  upon  him  by 
the  American  Red  Cross,  honorably  upholding  in  the  foreign 
war  zone  the  ideal  of  one  of  the  noblest  institutions  of  his  native 
land.  A  Christian  of  the  true  type  that  feared  not  to  face  death 
that  others  might  profit  by  his  labors." 

Dr.  M.  Jeanneret-Minkine  of  the  French  Mission  describes 
pathetically  the  conditions  as  he  observed  them  in  another  part 
of  Serbia.   Writing  of  his  hospital  in  Pirot  he  says : 

"At  first,  I  had  Serbian  wounded  who  had  become  ill,  but 
shortly  afterwards,  a  convoy  of  250  sick  prisoners,  many  of 
them  suffering  from  typhus,  arrived  and  was  sent  to  my 
hospital. 

''I  wish  to  draw  attention  to  the  following  fact  which  does 
great  credit  to  the  Serbians:  the  sick  prisoners  were  provided 
with  beds,  whereas  the  Serbian  soldiers  suffering  from  the 
same  disease  were  accommodated  in  other  hospitals,  in  which 
they  slept  on  straw  mattresses  placed  on  the  bare  floor. 

"As  I  already  had  several  cases  of  typhus  exanthematicus  in 
my  wards  and  was  anxious  to  protect  them  from  vermin,  I  gave 
the  following  careful  instructions  to  this  effect : 

"1.  Owing  to  the  absence  of  a  reception  room,  the  patients 
will  be  completely  undressed  in  the  entrance  hall  and  rapidly 
conveyed  on  stretchers,  naked,  covered  with  a  blanket,  to  the 
rooms  in  which  they  will  receive  clean  underclothing. 

"2.  The  discarded  clothes  will  immediately  be  put  on  a 
cart  and  taken  out  of  the  town;  they  will  subsequently  be 
spread  out  on  a  field  and  guarded  by  soldiers,  pending  their 
disinfection. 


12  TYPHUS  FEVER 

"3.  The  same  day,  a  steam  sterilizer  will  be  built  in  the 
yard  (the  pharmacy  could  not  supply  me  with  sufficient  sulphur 
to  proceed  by  sulphurization) . 

^^The  uniforms  of  all  the  male  nurses  were  immediately  de- 
loused  partly  in  the  small  autoclave  left  from  the  old  operating 
room  and  partly  by  boiling  in  the  kitchen  boilers.  The  walls  of 
the  rooms  were  washed  with  milk  of  lime. 

"The  convoy  arrived  during  the  night.  The  weather  w^s  ap- 
palling, cold  and  snowy.  Notwithstanding  that  the  patients 
were  half  frozen,  I  maintained  my  instructions,  and  saw  that 
they  were  enforced  with  regard  to  the  first  arrivals.  Then, 
being  obliged  to  superintend  the  removal  of  the  last  wounded 
to  the  neighboring  hospital,  I  was  absent  for  an  hour.  During 
that  time,  a  member  of  the  Administration  came  along,  and, 
disapproving  of  my  instructions,  had  the  patients  with  all  their 
clothes  on  carried  to  the  rooms  in  which  they  were  undressed. 

"The  uniforms  covered  with  vermin  were  only  then  col- 
lected together  in  the  corridors  and  sprinkled  with  diluted  lysin. 

"  Result :  My  wards  were  immediately  infested  with  vermin. 
The  uniforms  in  the  corridors  were  literally  alive,  which  gave 
me  the  opportunity  of  studying  their  biology. 

"While  I  was  asking  the  Administration  for  an  explanation, 
the  Superintendent  had  the  uniforms,  still  covered  with  vermin, 
locked  up  in  the  attic.  '  We  always  do  so,'  said  the  Chief  Ad- 
ministrator, '  but  only  wait  a  few  days,  and  everything  will  be 
changed.'  But  all  he  did  was  to  construct  elegant  portable 
W.C.'s.  He  believed  that  typhus  infection,  similarly  to  ty- 
phoid, was  carried  by  fecal  matter.  This  belief  cost  him  his  life. 

"As  regards  the  steam  sterilizer  of  which  I  had  drawn  a  plan, 
and  for  the  construction  of  which  I  required  bricks,  everybody 
agreed  with  me  about  it,  but  I  was  nevertheless  asked  to  wait  a 
few  days.   This  was  about  the  end  of  January. 

"During  these  'few  days,'  the  epidemic  spread  with  the 
rapidity  and  force  of  a  waterspout. 

"In  my  hospital,  most  of  the  Serbians  and  prisoners  admit- 
ted for  bronchitis  or  enteritis  contracted  typhus  through  infec- 
tion from  vermin.    Within  a  fortnight,  all  the  male  nurses 


THE  SERBIAN  EPIDEMIC  13 

became  ill  and  from  day  to  day  the  virulence  of  the  disease  was 
increased  by  the  rapid  transmission  from  man  to  louse  and 
louse  to  man.  The  mortality  increased  at  an  appalling  rate. 
From  15  per  cent  in  the  first  case,  it  rose  to  50  per  cent.  In 
other  hospitals  of  the  town  it  was  even  worse,  the  vermin  being 
still  more  abundant. 

''At  the  end  of  January,  the  surgeon  of  the  hospital  de- 
veloped typhus,  whilst  in  the  next  room  his  Austrian  colleague 
was  becoming  convalescent.  He  however  recovered.  The  same 
day,  a  Czech  doctor  was  taken  ill  and  died.  Within  the  next 
few  days,  the  Superintendent  of  the  hospital,  a  young  physician 
who  worked  under  my  supervision  in  an  improvised  hospital,  a 
PoUsh  surgeon  whose  room  I  had  just  moved  into,  the  Chief 
Administrator  of  Sanitation,  and  later,  a  Roumanian  doctor 
who  had  taken  his  wife  and  children  with  him  to  Pirot,  be- 
came infected.  All  died  one  after  the  other.  I  myself  con- 
tracted typhus  in  March. 

''In  short,  out  of  13  physicians  working  in  the  town  when  I 
arrived,  2  were  immunized  by  a  previous  attack  of  typhus,  2 
were  taken  ill  at  the  outbreak  of  the  epidemic  and  recovered, 
8  contracted  typhus  when  the  epidemic  was  at  its  height,  and  6 
died  within  a  month.    Only  one  escaped  unscathed. 

"The  disease  caused  similar  ravages  among  the  soldiers. 
Every  morning,  cars  drawn  by  small  thin  oxen  conveyed  piles  of 
coffins  from  the  mortuary  to  the  cemetery,  preceded  by  priests 
clad  in  sacerdotal  vestments  who  appeared  utterly  exhausted 
by  the  ceaseless  repetition  of  the  ceremony.  The  procession 
was  closed  by  a  territorial  guard,  detailed  day  after  day  to  this 
melancholy  task. 

"I  sometimes  saw  dead  bodies  piled  like  pieces  of  wood  in  the 
mortuary.  They  were  buried  almost  level  with  the  ground 
owing  to  the  lack  of  time.  Every  day,  the  cemeteries  were  ex- 
tended. The  long  lines  of  newly  dug  earth  gave  one  the  impres- 
sion of  a  field  ready  for  sowing. 

"As  the  number  of  victims  in  my  hospital  continued  to  in- 
crease, I  several  times  attempted  a  further  disinfection,  in 
which  I  was  only  partially  successful. 


14  TYPHUS  FEVER 

'^  I  was  unable  to  obtain  my  steam  sterilizer,  the  persons  who 
had  promised  it  having  died,  and  although  I  was  my  own  mas- 
ter as  regards  the  treatment  of  the  patients,  I  had  no  power  to 
requisition  equipment  without  authority  from  the  Administra- 
tion. 

^'When  visiting  the  wards,  I  each  day  saw  one  or  two  para- 
sites fall  onto  my  overall,  and  on  inspecting  my  underclothing, 
which  I  did  twice  every  day,  would  constantly  find  some.  Even 
the  linen  brought  back  from  the  laundry  was  not  free  from 
vermin.  Both  my  orderlies  became  infected  and  I  was  obliged 
to  allow  one  of  them  to  lie  down  near  the  stove  in  my  bed- 
room. There  was  no  room  for  him  in  the  wards  and  he  pre- 
ferred, not  without  reason,  dying  in  the  streets  rather  than 
entering  the  improvised  hospital  in  the  officers'  casino. 

''As,  apart  from  my  already  very  heavj''  work,  I  was  obliged 
to  supervise  other  hospitals  in  which  the  regular  doctors  were 
sick,  dead  or  inexperienced,  I  was  faced  with  the  alternative  of 
attending  to  the  patients  only  quite  superficially,  by  distribut- 
ing antithermics  and  digalen  as  had  become  customary  else- 
where, or  of  seeing  only  a  certain  number  of  cases  daily.  I 
decided  upon  the  latter  course  and  then  proceeded  to  select 
some  intelligent  prisoners  and  taught  them  how  to  judge  a 
pulse  and  how  to  assist  their  comrades  in  the  disinfection  of 
their  mouth  and  nose,  and  to  make  wet  packs  (maillots). 
These  assistants  were  each  put  in  charge  of  a  certain  number  of 
rooms  and  given  instructions  to  give  massive  subcutaneous  in- 
jections of  ethero-camphorated  oil  to  all  patients  whose  pulse 
commenced  to  fail.  In  this  way,  I  was  able  to  give  special  at- 
tention to  the  serious  cases,  those  passing  through  the  critical 
period  between  the  tenth  and  thirteenth  day,  and  depend  on 
my  assistants  for  the  others. 

''It  must  be  admitted  that  if  the  Serbians  showed  humanity 
in  treating  the  sick  Austrian  prisoners  on  the  same  footing  as 
their  own  soldiers,  the  prisoners  working  as  male  nurses  gave 
me  great  satisfaction  by  their  zeal,  courage,  and  devotion  to 
the  Serbians  and  to  their  compatriots.  Further,  when  several 
of  these  attendants  died  of  typhus,  there  was  no  difficulty  about 


THE  SERBIAN  EPIDEMIC  15 

replacing  them,  although  nobody  was  forced  to  undertake  the 
work  and  those  offering  their  services  were  warned  of  the  dan- 
ger. However,  in  a  month,  my  assistants  were  all  convalescent 
from  typhus  exanthematicus  and  were  thus  immunized. 

"At  the  end  of  February,  the  epidemic  still  continued;  yet 
not  a  single  hospital  possessed  a  sterilizer.  A  new  Administra- 
tor was  appointed  who  appeared  full  of  good  resolutions,  but 
who  lost  his  nerve  from  the  very  first.  He  was  moreover  no 
longer  young  and,  feigning  sickness,  did  not  appear  until  the 
epidemic  had  of  itself  commenced  to  subside. 

"In  the  barracks  the  epidemic  claimed  many  victims  among 
the  recruits  sleeping  on  the  bare  floor  in  the  long  dormitories, 
with  straw  mattresses  as  pillows.  Their  doctors  made  every 
effort  to  combat  the  disease,  the  whole  regiment,  squad  after 
squad,  being  sent  to  the  station  of  the  military  hospital  reserved 
for  them  where  they  were  given  shower  baths  and  their  clothes 
disinfected  by  steam.  The  vermin  however  persisting,  I  con- 
cealed tiny  bags  of  paper  filled  with  parasites  and  ova  in  the 
uniforms.  When  they  had  been  steamed  for  half  an  hour  at 
80°  C,  I  found  that  the  big  ones  were  all  dead,  but  several  of  the 
smaller  ones  revived  after  being  on  the  skin  of  a  convalescent 
patient  for  an  hour,  on  which  I  had  placed  them  wrapped  in  a 
piece  of  linen  covered  with  sparadrap.  In  some  of  the  ova,  the 
movements  of  the  air  bubbles  inside  showed  that  the  embryo 
was  still  alive.  It  was  therefore  necessary  to  heat  the  sterilizer 
to  100°  C.  and  to  leave  the  uniforms  in  it,  less  tightly  packed, 
for  half  an  hour  after  this  temperature  had  been  obtained. 
Moreover,  in  the  larger  wards,  the  recruits  who  had  just  been 
deloused  were  reinfected  by  the  men  who  had  not  yet  been 
disinfected. 

"The  civilian  population  did  not  suffer  much  from  the  epi- 
demic, with  the  exception  of  the  refugees  and  those  in  com- 
munication with  the  hospital.  Even  the  peasant  women  who, 
although  they  should  have  been  forbidden  to  do  so,  visited  their 
sick  husbands  on  market  days,  rarely  carried  infection  to  their 
villages  as  they  were  clean  and  fought  the  vermin.  In  the 
town,  at  the  sight  of  workmen  busy  painting  names  on  new 


16  TYPHUS  FEVER 

coffins,  the  women  sitting  outside  their  doors  did  not  stop 
weaving  and  spinning  the  many  colored  tapestries  which  are 
the  glory  of  their  town.  And  when  a  group  of  Czech  prisoners 
organized  a  concert  at  which,  after  the  Russian  anthem,  the 
Serbian  anthem,  and  the  Marseillaise,  music  by  Wagner  was 
played,  the  hall  was  crowded. 

''I  have  already  mentioned  the  very  important  part  played 
by  fear  in  the  prognosis  of  typhus  exanthematicus,  so  will  not 
refer  to  it  again.  I  wish  however  to  say  how  much  I  was  im- 
pressed by  the  ease  with  which  one  became  accustomed  to  the 
idea  of  death,  even  of  death  without  glory,  from  infectious  dis- 
ease. We  watched  our  group  of  physicians  and  hospital  em- 
ployees rapidly  diminish;  the  merry  party  round  the  dining 
room  table  was  reduced  to  three,  but  nevertheless  remained 
optimistic.  Without  any  effort  we  had  become  used  to  the  dan- 
ger threatening  us  and  faced  it,  smile  on  lip  and  joke  ever 
ready,  like  soldiers  at  the  front.  It  is  a  curious  psychological 
phenomenon  that  the  fact  of  seeing  so  many  people  die,  causes 
one  to  regard  death  as  a  very  common  event,  even  when  it  is  a 
question  of  one's  own  death.  Life  is  very  busy  and  there  is  an 
adversary  to  be  fought;  the  situation  may  be  likened  to  an 
exciting  game  of  checkers  which  absorbs  you  and  makes  you 
forget  all  the  rest.  Also  one  has  faith  in  one's  good  star.  The 
reason  for  that  man's  death  was  no  doubt  because  he  was 
afraid;  the  one  over  there  was  no  longer  young;  that  other  had 
over-disinfected  himself  with  alcohol,  another  was  too  thin  or 
too  fat,  etc.  One  even  went  so  far  as  to  believe  that  typhus 
would  not  be  dangerous  for  one's  self  and  was  almost  glad  to 
contract  it  in  order  to  find  out  what  it  was  like! 

''And  meanwhile,  the  epidemic  continued  its  ravages.  By 
the  end  of  February,  the  number  of  physicians  who  had  died 
from  typhus  in  the  Serbian  reserve  hospitals  exceeded  100, 
representing  almost  a  third. 

''I  was  obliged  to  go  to  Nish  and  found  the  hospitals  there 
better  equipped  than  those  of  Pirot;  they  were  however  simi- 
larly crowded.  I  was  asked  out  to  dinner  by  one  of  my  friends 
and  found  one  of  my  fellow-students  delirious  with  typhus  in  a 


THE  SERBIAN  EPIDEMIC  17 

corner  of  the  room  in  which  we  were  eating.  In  the  neighbor- 
ing hospital,  another  colleague  who  had  come  from  Switzerland 
was  dying,  without  my  knowing  of  his  illness.  In  every  town 
the  epidemic  was  raging.  In  one,  as  I  was  passing  the  cemetery, 
I  saw  more  than  200  coffins  standing  out  on  the  snow,  waiting 
to  be  put  in  the  earth.  The  heads  of  the  Sanitary,  Department 
may  have  been  anxious,  but,  in  Serbian  medical  circles,  a  feel- 
ing of  fatalism  and  powerlessness  prevailed.  The  Chief  of  the 
Belgrade  Pasteur  Institute,  to  whom  I  expressed  my  amaze- 
ment at  seeing  only  anodyne  measures  employed,  himself  told 
me  that  he  was  counting  upon  the  spontaneous  extinction  of 
the  epidemic. 

^' At  Uskub,  I  at  last  saw  a  hospital  free  from  typhus.  It  be- 
longed to  an  English  Mission  with  a  well-trained  personnel, 
beds,  a  sufficient  quantity  of  linen,  and  which  above  all  ac- 
cepted only  a  limited  number  of  wounded  per  room  and  per 
doctor. 

''With  this  exception,  from  Ghevgheli  in  the  extreme  south  to 
Valjevo  in  the  north,  typhus  had  spread  to  all  the  hospitals  of 
which  I  heard  or  which  I  visited.  Everywhere,  I  saw  the  same 
leaden-hued  faces  with  an  absent  or  stupid  look  in  the  eyes,  the 
some  long  rows  of  straw  mattresses  on  which  the  unfortunate 
soldiers  were  huddled  together,  semiclothed  in  their  uniforms, 
or  again  those  beds  which  many  doctors  did  not  dare  to  ap- 
proach. 

"Fortunately,  the  first  line  troops  did  not  suffer  as  much  as 
the  others,  the  febrile  cases  being  immediately  evacuated  and, 
an  excellent  measure,  the  soldiers  and  even  the  officers  being 
forbidden  to  leave  the  zone  of  operation  for  fear  of  infection  in 
the  towns. 

"In  March,  during  the  full  period  of  incubation  of  typhus,  I 
left  the  country.  An  international  hygiene  commission  was 
shortly  after  appointed.  The  allied  countries  then  despatched 
a  considerable  number  of  courageous  physicians  to  Serbia.  In 
May  and  June  the  cases  of  petechial  exanthematicus  were  less 
frequent  than  in  February,  and  in  August  there  were  only 
sporadic  cases.   The  epidemic  therefore  appears  to  be  over." 


18  TYPHUS  FEVER 

These  quotations,  together  with  the  descriptions  I  have  at- 
tempted to  give,  it  is  hoped  will  convey  to  the  reader  some  idea 
of  the  situation. 

Origin  of  the  Epidemic 

Such,  then,  were  the  conditions  which  Serbia  was  facing 
when  the  medical  authorities,  worn  out  and  overwhelmed  by 
the  increasing  magnitude  of  the  epidemic,  became  convinced 
that  outside  assistance  should  be  asked  for.  Accordingly  the 
government  of  Serbia  appealed  for  foreign  assistance  in  com- 
bating the  disease  which  was  fast  rendering  her  army  inert  as  a 
fighting  machine  and  bringing  about  general  demoralization  of 
the  country.  The  vahant  part  which  Serbia  had  played  in  the 
history  of  the  war  is  too  well  known  to  make  it  necessary  to 
emphasize  the  fact  that  Serbia  was  justified  in  both  asking  for 
aid  from  her  Allies  in  this  connection,  and  in  expecting  that 
such  aid  should  be  rendered  her. 

It  will  be  recalled  that  in  July,  1914  Austria-Hungary  de- 
clared war  against  Serbia  and  immediately  thereafter  launched 
a  severe  attack  which  came  as  a  surprise  to  the  Serbian  army 
and  compelled  it  to  fall  back.  Belgrade,  the  capital,  was  bom- 
barded and  the  government  retired  to  Nish  which  became  the 
new  capital  throughout  the  period  of  the  epidemic.  The  Aus- 
trians,  however,  did  not  immediately  follow  up  this  first  at- 
tack and  in  their  subsequent  attempts  to  cross  the  Danube  and 
the  Sava  in  the  vicinity  of  Belgrade,  they  were  always  re- 
pulsed. A  more  severe  and  concentrated  attack,  however,  was 
launched  later  by  the  Austrians  along  the  Bosnian  border,  be- 
tween Schabatz,  Valjevo,  and  Ujitze,  the  Austrians  forcing 
their  way  across  the  Sava  and  Drina  rivers  at  several  points 
with  the  object  of  separating  the  Serbian  armies  at  Valjevo. 
This  Austrian  invasion  was  pursued  with  great  bitterness  and 
was  characterized  by  many  cruelties  to  the  civilian  Serbian  pop- 
ulation. After  five  days'  fighting  in  the  valley  of  the  Yadar  the 
Austrians  were,  however,  repulsed  and  driven  back  across  the 
Drina,  20,000  Austrian  prisoners  remaining  in  the  hands  of 
the  Serbian  army.  In  September  the  Austrians  again  attacked 
along  the  Bosnian  border.   They  were  unable  at  first  to  make 


THE  SERBIAN  EPIDEMIC  19 

any  material  advance,  but  gradually  the  Serbian  army  was 
compelled  to  shorten  its  line  and  fall  back.  In  November  the 
Austrians  attacked  and  advanced  in  great  force,  this  time 
capturing  Valjevo.  Belgrade  had  also  to  be  given  up,  the 
Austrians  occupying  on  December  2  a  line  extending  from 
that  city  to  a  point  about  40  miles  east  of  Ujitze.  The  situation 
of  the  Serbian  army  was  then  precarious,  it  being  exposed  both 
on  the  north  and  west  flanks.  However,  with  great  fortitude 
the  Serbians  took  the  offensive  again  and  a  few  days  later  they 
drove  the  Austrians  back  through  Valjevo  and  across  the 
Drina  and  Sava  rivers,  once  more  occupying  Belgrade  thirteen 
days  after  its  second  capture  by  the  Austrians. 

Cases  of  tjrphiis  fever  had  undoubtedly  occurred  in  the  Ser- 
bian army  in  October  and  November,  1914,  the  infection  hav- 
ing apparently  been  introduced  from  Albania,  but  no  epidemic 
resulted.  Typhus,  however,  was  present  in  the  Austro-Hun- 
garian  army  when  it  invaded  Serbia.  After  the  Austrians  re- 
treated in  December,  when  the  Serbians  had  reoccupied  the 
invaded  territory,  a  large  number  of  Austrians,  both  wounded 
and  sick,  many  with  typhus  and  relapsing  fever,  were  left  be- 
hind, and  these  were  found  living  under  most  unsanitary  condi- 
tions. It  was  necessary  to  confine  these  and  the  other  prisoners. 
As  there  was  very  little  available  shelter  they  were  crowded 
together  in  buildings  where  proper  sanitary  conditions  were 
impossible,  and  the  number  of  typhus  cases  rapidly  increased 
among  them.  Many  individuals  who  came  into  contact  with 
them  were  also  attacked.  This  was  particularly  the  case  at 
Valjevo  which  had  been  the  Austrian  military  headquarters. 
It  was  in  this  city,  situated  in  the  northwestern  portion  of 
Serbia,  that  the  disease  first  began  to  appear  in  serious  form 
among  the  Austrian  prisoners,  and  from  them  it  quickly  spread 
to  the  Serbians  who  had  reoccupied  the  territory.  With  60,000 
prisoners  to  care  for,  many  already  ill  with  typhus,  the  newly 
arrived  troops,  the  refugees  and  wounded  in  this  district,  the 
available  shelter  was  far  from  sufficient.  Immediate  steps  were 
therefore  taken  to  evacuate  many  of  the  sick  and  wounded, 
both  by  the  railway  which  leads  from  Valjevo  as  well  as  by  the 


20  TYPHUS  FEVER 

carriage  roads.  The  Austrian  prisoners  were  also  separated 
into  groups,  and  distributed  throughout  the  country.  The 
seriousness  of  the  situation  from  a  sanitary  point  of  view  was 
not  reahzed;  the  patients  infected  with  typhus  were  not  isolated 
but  were  allowed  to  go  to  their  homes  or  were  sent  to  various 
parts  of  the  country,  introducing  and  spreading  the  infection  to 
other  troops,  to  households,  or  to  the  inmates  of  hospitals.  No 
quarantine  was  placed  upon  the  districts  in  which  the  typhus 
cases  were  particularly  occurring,  and  hence  in  a  very  short 
time  the  greater  proportion  of  the  country  was  afflicted  with  a 
terrible  epidemic.  The  epidemic  increased  through  January, 
rose  more  rapidly  in  February  and  March,  and  reached  its 
height  in  April  when  the  number  of  cases  in  the  army  and  civil- 
ian population  was  in  the  neighborhood  of  9000  per  day. 
Those  figures  are  only  approximate  because  when  I  reached 
Serbia  there  were  no  available  statistics  of  the  number  of  cases 
or  deaths  in  the  various  towns  throughout  Serbia,  and  only  an 
approximate  number  of  the  sick  in  the  military  hospitals  could 
be  furnished. 

Organization 

In  America  the  response  to  Serbia's  appeal  for  aid  in  com- 
bating the  epidemic  was  almost  immediate,  and  as  the  United 
States  had  not  yet  entered  the  war  the  American  Red  Cross 
responded  to  this  appeal,  and,  recognizing  the  seriousness  of 
the  situation,  decided  to  send  a  sanitary  commission,  thor- 
oughly equipped  with  materials  and  supplies,  for  the  purpose  of 
eradicating  the  disease,  in  addition  to  the  hospital  units  which 
it  had  already  sent  and  which  were  performing  such  excellent 
work  in  connection  with  caring  for  and  treating  the  sick.  The 
Rockefeller  Foundation  was  interested  in  this  sanitary  com- 
mission from  the  time  of  its  organization,  and  generously  sup- 
ported it  with  funds  in  connection  with  the  American  Red 
Cross.  Great  Britain,  France,  and  Russia  also  recognized  the 
extreme  gravity  of  the  epidemic  and  the  terrible  ravages 
caused  by  the  disease  and  sent  relief  expeditions,  though 
largely  from  a  military  standpoint,  to  help  in  the  situation. 


Fig.  1.    The  black  flags  indicate  deaths 
from  typhus  within  the  houses 


Fig.  2.     Typhus  victims  awaiting  burial 


PLATE  II 


■&■. 


% 


THE  SERBIAN  EPIDEMIC  21 

Owing  to  the  ravages  caused  by  the  spread  of  the  disease,  al- 
most complete  demoralization  had  resulted  in  many  parts  of 
Serbia.  So  many  officials  had  succumbed  to  the  disease  that  a 
number  of  the  remaining  ones,  apparently  in  the  depths  of 
despair  and  thoroughly  discouraged  at  the  appalling  conditions 
and  the  responsibilities  which  they  had  been  called  upon  to 
face,  appeared  to  be  reluctant  or  unable  to  even  attempt  to  deal 
further  with  the  situation.  A  number  of  them  forsook  their 
offices  and  remained  most  of  the  time  gloomily  in  their  resi- 
dences. Almost  every  Serbian  family  was  in  mourning  for 
some  relative  or  friend,  and  the  black  flags  outside  the  houses, 
the  sign  of  death  within,  were  very  common  throughout  the 
towns. 

One  of  the  most  immediate  and  important  problems  which 
confronted  me  after  my  arrival  in  Serbia  was  that  of  central 
organization  and  control,  so  that  absolute  authority  over  all 
sanitary  matters  throughout  Serbia  could  be  secured.  Owing 
to  the  loss  through  sickness  and  death  of  many  of  Serbia's 
most  efficient  physicians  and  sanitarians,  such  central  control 
was  not  being  exercised,  and  no  general  campaign  of  attacking 
the  epidemic  throughout  the  country  was  being  pursued, 
though  individual  relief  and  hospital  units  were  already  at 
work  in  connection  with  the  disease.  Under  the  conditions 
which  existed,  and  which  I  have  attempted  briefly  to  outline, 
it  could  perhaps  hardly  have  been  otherwise.  When  I  first  ar- 
rived in  Serbia,  the  services  of  several  foreign  relief  units 
which  had  arrived  were  not  being  employed  at  all  and  had  not 
even  been  assigned  stations,  and  in  some  instances  there  ap- 
peared to  be  a  diffidence  on  the  part  of  some  of  the  Serbian 
sanitary  officers  in  making  assignments  of  the  duties  of  the 
foreign  units  and  of  supervising  their  work.  Such  voluntary 
relief  units  as  were  at  work,  and  the  majority  were  performing 
truly  heroic  service  in  treating  the  sick,  were  pursuing  their 
duties  almost  independently  of  one  another,  and  two  units 
from  the  same  country  were  found  to  be  working  almost  side 
by  side  with  a  different  plan  of  action.  Such  central  organiza- 
tion and  control  of  sanitary  measures  throughout  Serbia  was, 


22  TYPHUS  FEVER 

however,  secured  through  the  estabhshment,  with  the  consent 
and  aid  of  the  Serbian  government,  of  an  International  Sani- 
tary Commission  whose  resolutions  were  immediately  enforced 
when  necessary  through  the  Ministers  of  the  Interior  and  of 
War.  In  addition,  the  Medical  Director  of  this  Commission 
was  invested  with  the  necessary  authority  in  sanitary  matters 
and  in  sanitary  reform.  This  organization  was  effected  par- 
ticularly through  the  assistance  of  M.  Pachitch,  Minister  of 
Foreign  Affairs,  M.  L.  Jovanovitch,  Minister  of  the  Interior, 
Sir  Charles  des  Graz,  British  Minister,  and  M.  Bopp,  French 
Minister  to  Serbia.  Assistant  Secretary  of  Foreign  Affairs, 
Slavko  Grouitch,  now  Serbian  Minister  to  the  United  States, 
and  Sir  Ralph  Paget,  former  British  Minister  to  Serbia,  who 
had  been  placed  in  charge  of  the  medical  units  in  Serbia  from 
Great  Britain,  were  also  of  very  great  assistance  in  bringing 
about  this,  organization.  At  my  preliminary  conferences  with 
some  of  the  Serbian  officials,  it  was  feared  that  this  organiza- 
tion might  lead  to  some  friction  among  the  Allies,  but  no  ap- 
preciable difficulties  of  this  nature  were  encountered.  The 
commissions  finally  consisted  of  Sir  Ralph  Paget,  Commis- 
sioner of  British  Relief  Units  in  Serbia;  Colonel  Karanovitch, 
Chief  of  the  MiUtary  Sanitary  Department,  Serbia;  Dr.  Ni- 
kolitch.  Commissioner  of  Health,  Serbia;  Colonel  Sondermeyer, 
Chief  Inspector  of  MiUtary  Hospitals  (representative  from  the 
Serbian  Parhament) ;  Colonel  Jaubert,  in  charge  of  the  French 
Relief  Units  in  Serbia;  and  Colonel  Solfatero,  in  charge  of  the 
Russian  Relief.  The  Prince  Regent  Alexander  was  asked  to  act 
as  Honorary  President,  Sir  Ralph  Paget  as  Vice-President, 
Lieutenant  Petronovitch  as  Secretary,  and  the  writer  served  as 
Medical  Director.  The  headquarters  of  this  Commission  were 
situated  at  the  war  capital  of  the  government  in  Nish.  The 
country  having  been  divided  into  sanitary  districts,  sanitary 
personnel,  or  hospital  units,  sanitary  stations  and  hospitals 
were  assigned  or  distributed  to  these. 


'^"■'■'^gw 


mwM^^z 


Fig.  1.     Camp  of  unit  of  American  Red  Cross  Sanitary  Commission 


Fig.  2.    Professor  Zinsser  and  Dr.  Maitland  at  the 
Paget  ttphus  hospital 


PLATE  III 


THE  SERBIAN  EPIDEMIC  23 


Preventive  Measures 


The  general  plan  of  the  campaign  against  typhus  included: 
general  disinfestation  of  people  in  badly  infected  districts; 
general  house-to-house  inspection  in  such  districts  with  re- 
moval of  patients  to  hospitals  for  typhus  cases;  disinfestation 
of  other  inmates  of  such  houses;  disinfection  or  disinfestation 
of  houses  from  which  patients  were  taken  or  in  which  deaths 
from  typhus  had  occurred;  the  establishment  of  quarantine 
and  bathing  and  disinfesting  stations  at  important  points 
throughout  the  country;  the  limitation  of  railway  travel  by  re- 
ducing the  number  of  passenger  trains;  and  the  establishment 
of  a  system  of  limited  travel  permits  and  of  inspection  of  travel- 
ers, only  cars  with  wooden  seats  with  no  upholstery  being  per- 
mitted to  be  run;  provision  for  the  cleaning  and  disinfecting  of 
such  cars  after  each  journey;  provision  for  the  cleaning  and  dis- 
infestation of  public  vehicles,  particularly  of  cabs  at  the  railway 
stations;  the  sanitary  inspection  of  restaurants  and  cafes,  and 
the  establishment  of  regular  hours  of  closing  during  the  day  for 
cleaning  and  disinfection,  and  the  methods  to  be  employed  for 
such  disinfection;  regulations  for  hospitals  in  connection  with 
the  disinfestation  of  the  wards,  beddings,  and  hnen,  and  of  the 
inmates  and  their  clothing;  the  establishment  of  free  dis- 
pensaries in  various  cities,  not  only  for  the  treatment  of  the 
sick  but  for  the  early  detection  of  individuals  suffering  with 
infectious  disease;  a  campaign  of  education  with  printing  and 
distribution  of  circulars  in  the  Serbian  language  regarding  the 
nature  of  the  disease,  the  manner  of  its  spread,  and  the  pre- 
cautions to  be  taken  to  avoid  infection. 

After  the  general  plan  of  the  campaign  was  prepared,  it  was 
necessary  to  have  accurate  information  as  to  the  sanitary  con- 
ditions and  the  needs  of  the  different  districts  in  various  parts 
of  the  country,  and  it  was  found  to  be  absolutely  impracticable 
to  obtain  such  information  unless  an  actual  visit  had  first  been 
made  to  the  district  concerned.  Hence  a  system  of  sanitary 
inspection  was  inaugurated.  Much  work  of  this  nature  was  also 


24  TYPHUS  FEVER 

carried  on  personally  by  the  writer  and  it  involved  frequent 
journeys  made  in  as  quick  a  time  as  possible. 

The  usual  method  employed  in  these  primary  inspections 
was  comparatively  simple.  Upon  arriving  at  a  town  a  con- 
ference was  called  of  the  prefect,  the  chief  of  police,  the  mihtary 
commander,  and  the  senior  military  and  civil  medical  officers 
for  the  locaUty.  After  this  conference,  inspections  would  be 
made  with  these  gentlemen  and  a  plan  made  for  the  carrying 
out  of  such  sanitary  measures  as  seemed  necessary.  The  req- 
uisite sanitary  personnel  and  supphes  not  at  hand  were  then 
sent  to  the  district.  Almost  invariably  at  a  later  date  reinspec- 
tion  of  the  district  was  carried  out  in  order  to  ascertain  whether 
the  sanitary  measures  in  question  had  been  or  were  being 
actually  carried  out  in  a  satisfactory  manner. 

For  the  purpose  of  making  these  inspections,  the  Serbian 
government  placed  at  my  disposal  a  railway  car,  approxi- 
mately half  of  which  was  fitted  up  with  four  sleeping  berths, 
with  shower  bath  and  toilet  facilities,  while  the  other  half 
served  as  an  office  and  dining  room.  Although  these  quarters 
were  not  as  palatial  as  this  brief  description  of  them  might 
imply,  they  constituted  as  regards  disease  one  of  the  safest 
places  in  which  to  sleep  in  Serbia.  Attached  to  this  car  was  a 
second  flat  car  upon  which  two  Ford  automobile  trucks  were 
carried.  It  was  necessary  to  carry  these  automobiles  because 
the  railways  in  Serbia  are  very  few  in  number  (in  fact  there  are 
only  three  main  fines)  and  the  great  majority  of  the  smaller 
towns  are  situated  away  from  the  track,  often  at  considerable 
distances  from  the  stations.  When  it  was  necessary  to  spend 
the  night  in  the  open  the  second  Ford  truck  was  employed  to 
carry  tents  and  supplies. 

None  of  the  hotels  or  inns  were  safe  places  in  which  to  sleep 
before  being  disinfested  or  unless  one  took  special  precautions 
in  connection  with  a  sleeping  uniform,  and  one  enjoyed  the 
luxury  of  a  tent  in  Serbia  whenever  there  was  an  opportunity  to 
sleep  in  one.  The  Ford  automobiles  were  found  to  be  most  use- 
ful, particularly  because,  on  account  of  the  very  muddy  and 
very  bad  roads,  heavy  cars  could  not  be  employed.    It  was 


Fig.  1.     Type  of  motor  trxjck  most  successfully  employed 


<mBM 

■Kt*    "i  "*!%»  i  1 

^hR 

■UHHfi 

HBBHBI^^''^—*^*™ 

" 

Fig.  2.     Disinfection  of  carriages 


PLATE  IV 


THE  SERBIAN  EPIDEMIC  25 

usually  a  simple  matter,  with  the  assistance  of  one  or  two  sol- 
diers, to  dig  out  the  car  when  the  wheels  sank  into  the  mud 
above  the  hubs  (a  not  infrequent  occurrence)  and  to  then  con- 
tinue upon  the  journey. 

In  making  the  inspections  just  referred  to  every  effort  was 
made  to  awaken  interest  among  the  people  in  combating  the 
disease  and  particularly  to  arouse  to  action  the  officials  of  the 
district  as  well  as  the  people  in  connection  with  the  prevention 
of  the  spread  of  the  epidemic.  The  Serbian  official,  though  al- 
most invariably  good-natured,  is  often  apt  to  procrastinate  in 
connection  with  work  which  requires  particular  effort  or  in- 
convenience, and  considerable  driving  power,  initiative,  and 
assumption  of  authority  was  often  necessary  in  order  to  accom- 
plish what  was  deemed  necessary.  Obviously  it  sometimes 
sorely  taxed  the  patience  of  a  Serbian  military  commander  to 
be  informed,  for  example,  that  a  certain  sanitary  measure 
which  required  the  performance  of  considerable  labor  should  be 
immediately  carried  out,  or  that  other  more  healthy  prison 
quarters  must  be  found  for  several  thousand  Austrian  prison- 
ers and  certain  sanitary  measures  insisted  upon  in  the  new 
prison.  While  the  authority  vested  in  the  writer  by  the  Serbian 
government  was  ample  enough  to  secure  in  the  end  the  carry- 
ing out  of  all  sanitary  measures  considered  necessary  in  con- 
nection with  the  epidemic,  nevertheless  I  have  often  thought 
that  the  natural  cordiality  and  politeness  of  Serbian  officials  to 
a  foreigner  often  accounted  for  the  good-natured  manner  in 
which  they  usually  acquiesced  in  carrjdng  out  a  piece  of  work  in 
connection  with  the  epidemic,  after  they  had  been  thoroughly 
convinced  that  there  was  no  other  course  to  pursue. 

Occasionally  certain  sanitary  measures  of  importance  were 
of  such  a  nature  (for  example,  the  entire  evacuation  of  certain 
badly  infected  districts  and  the  destruction  of  buildings  by 
burning,  or  the  making  of  cholera  vaccination  general  and  com- 
pulsory) as  to  render  the  enactment  of  special  ordinances  de- 
sirable. When  such  special  enactments  were  desired,  they  were 
immediately  presented  and  secured  at  a  meeting  of  the  Inter- 
national Sanitary  Commission.   The  immediate  construction  of 


26  TYPHUS  FEVER 

disinfesting  stations  and  other  sanitary  measures  often  required 
special  and  immediate  expenditure  of  funds,  it  being  inadvisa- 
ble to  wait  for  special  appropriations  from  the  Serbian  Parlia- 
ment. Funds  for  carrying  on  the  campaign  had  already  been 
placed  at  the  disposal  of  the  writer  by  the  American  Red  Cross 
and  the  Rockefeller  Foundation,  and  these  were  immediately 
available  for  emergency  work.  The  writer  had  also  been  pro- 
vided with  different  funds  from  private  sources  which  will  be 
referred  to  later  in  this  Report. 

As  scientific  experiment  and  evidence  have  demonstrated 
that  typhus  fever  is  commonly  transmitted  from  man  to  man 
by  the  louse  Pediculus  humanus,  and  as  this  disease  is  com- 
monly transmitted  only  in  this  manner,  the  bathing  and  disin- 
festing of  large  numbers  of  people  and  of  their  clothing  in  a 
short  space  of  time  was  another  urgent  problem  in  connection 
with  the  Serbian  epidemic,  and  under  the  circumstances  it  was 
imperative  to  use  all  available  suitable  existing  apparatus  and 
to  hastily  improvise  all  conceivable  appliances  for  disinfesta- 
tion. 

It  was  very  necessary  to  lay  special  emphasis  upon  impro- 
vised methods  derived  from  whatever  materials  there  were  at 
hand,  as  very  little  perfected  apparatus  was  available  or  could 
be  secured. 

In  this  connection  it  should  be  particularly  emphasized  that 
one  of  the  reasons  why  the  epidemic  was  dealt  with  so  success- 
fully was  because  the  people  themselves  were  instructed  and 
were  finally  convinced  of  the  fact  that  the  disease  was  avoid- 
able and  that  the  epidemic  could  be  arrested  largely  through 
their  own  efforts  if  the  proper  assistance  was  rendered  them.  It 
was  not  that  the  great  majority  enjoyed  taking  a  bath  or  being 
deloused,  or  having  their  clothing  deloused.  In  fact,  many  had 
not  had  a  bath  for  over  a  year;  in  some  instances,  their  faces 
betrayed  surprise,  in  others  fear,  when  the  water  from  the 
shower  bath  touched  their  bodies.  Many  of  them  desired  none 
of  these  things,  but  they  submitted  to  these  inconveniences,  in 
fact  often  welcomed  them,  and  did  their  part  in  seeing  that 
they  were  carried  out,  solely  in  order  that  they  might  not  con- 


tm  1 

HM' 

■fl 

^P^^ 

l^^S 

Ihh 

^^H^^^^^r^K  ^^|e^"' -^ 

*m9|^r,c  V  in  "^fl^jHMfljuH^HI 

V^H 

■». 

^^^     «^^^^^^^RH 

Fig.  1.    Evacuation  op  badly  infected  disteict  prior  to  its  DESTRtrcTiON 

BY  BURNING 


Fig.  2.    The  usual  method  op  transportation  in  Serbia 


PLATE  V 


Figs.  1  and  2.    Refugees  for  disinfestation 


PLATE  VI 


THE  SERBIAN  EPIDEMIC  27 

tract  the  disease  and  that  the  epidemic  should  be  arrested  and 
that  they  should  be  freed  from  the  dangers  and  inconveniences 
which  it  entailed. 

When  I  was  first  asked  to  go  to  Serbia  to  take  charge  of  work 
in  connection  with  the  eradication  of  typhus,  I  was  strongly  ad- 
vised on  two  occasions  by  prominent  members  of  the  medical 
profession  against  undertaking  the  work.  It  was  argued  that  in 
order  to  exterminate  typhus  from  Serbia  it  was  necessary  to  up- 
lift the  whole  race  of  Serbian  people  and  to  change  their  entire 
habits  and  methods  of  living  and  that  this  would  take  years  to 
accomplish.  At  a  recent  important  conference  of  international 
sanitarians  I  heard  another  physician  express  a  somewhat 
similar  opinion,  namely,  that  before  the  typhus  epidemic  in 
Poland  could  be  put  down,  it  would  be  necessary  to  elevate  the 
entire  moral  tone  of  the  people  and  their  mode  of  living.  I  am 
not  in  agreement  with  this  idea.  I  however  do  believe  that 
such  conditions  must  probably  be  brought  about  in  a  country 
where  typhus  has  long  been  endemic  if  one  is  to  rid  it  entirely 
of  all  its  endemic  foci  of  this  disease,  but  experience  in  Serbia 
has  demonstrated  that  an  epidemic  of  typhus  may  be  arrested 
long  before  an  appreciable  advance,  however  desirable  it  may 
be,  has  been  made  in  uplifting  the  people  and  changing  their 
entire  habits  and  mode  of  living.  The  presence  of  tj^hus  fever 
in  times  of  famine,  squalor,  etc.,  is  obviously  particularly  due 
to  the  fact  that  among  people  who  are  more  or  less  starved, 
widespread  neglect  of  personal  cleanliness  occurs  and  an  in- 
creased prevalence  of  lousiness  results.  The  feeding  of  such 
individuals  and  the  improvement  of  their  nourishment,  how- 
ever, does  not  necessarily  change  permanently  their  entire 
habits  and  mode  of  life.  The  epidemic  of  typhus  in  Serbia  was 
not  accompanied  by  general  starvation  or  famine  and  it  was 
entirely  eradicated  after  six  months  intensive  work,  but  I  be- 
lieve that  the  habits  of  the  people  will  show  very  little  per- 
manent change  as  a  result  of  the  measures  undertaken.  The 
majority  of  the  people,  I  think,  will  not  delouse  and  bathe 
themselves  very  much  more  frequently  than  they  did  formerly 
unless  typhus  should  again  visit  them  in  epidemic  form,  and 


28  TYPHUS  FEVER 

they  will  then  undertake  these  inconvenient  and  perhaps  to 
many  of  them  disagreeable  measures  again,  not  because  they 
are  uplifted  and  their  habits  of  life  permanently  changed,  but 
because  they  have  been  enlightened  as  to  how  to  avoid  the 
infection  and  prevent  another  epidemic. 

In  the  emergency  which  confronted  us  in  Serbia,  it  often  be- 
came imperative,  as  I  have  intimated,  to  improvise  on  the  spot 
the  requisite  apparatus  for  disinfesting  and  bathing,  and  make- 
shift methods  of  various  types  were  then  devised.  The  ma- 
jority of  these  did  not  attain  what  might  be  regarded  as  high 
standards  of  efficiency  as  disinfestors,  but  they  usually  served 
their  purpose  in  destroying  lice  and  their  ova.  It  is  true  there 
were  not  in  Serbia  any  of  the  excellent  Thresh  steam  disin- 
festors on  5-ton  Foden  steam  lorries  nor  other  similar  types  of 
perfected  disinfestors.  Indeed  there  were  very  few  disinfestors 
in  the  country  which  could  be  considered  of  the  most  modern 
type.  It  however  was  impossible  to  obtain  better  types  in  time 
for  them  to  be  of  any  value,  and  therefore  their  employment 
was  out  of  the  question.  All  portable  steam  disinfestors  which 
were  present  in  the  country  were  sought  out  by  means  of  the 
sanitary  inspections  I  have  referred  to  above.  They  were  re- 
paired if  necessary  and  all  put  into  regular  use.  But  while  the 
use  of  the  highly  perfected  steam  machines  such  as  the  5-ton 
Thresh  is  obviously  very  desirable  in  an  epidemic,  experience 
in  the  Serbian  outbreak  demonstrated  that  they  were  not  ab- 
solutely essential  for  overcoming  the  outbreak.  One  may  in- 
deed, when  it  is  necessary,  successfully  combat  typhus  with 
such  essentials  as  improvised  baths,  clean  clothing,  fire  for  pro- 
ducing heat,  roughly  constructed  disinfestors  of  boards,  bricks, 
and  earth,  combined  with  sulphur  and  petroleum. 

In  such  makeshift  work  the  Serbian  people  often  showed 
themselves  not  inefficient.  It  was  frequently  only  necessary  to 
sufficiently  insist  that  there  must  be  a  bathing  and  disinfesting 
plant  in  a  district  and  to  give  an  idea  of  what  was  to  be  ac- 
compfished  in  order  for  the  Serbians  to  carry  out  the  project  in 
some  way,  though  it  was  often  performed  in  what  today  would 
be  considered  a  very  crude  manner. 


Fig.  1.     Women  .'^nd  children  "about  to  be  bathed  and  disinfected 


Fig.  2.     Austrian  prisoners  about  to  be  deloused 


PLATE  VII 


Figs.  1  and  2.    Refugee  women  and  children,  and  men  after  bathing 

AND   DISINFESTATION 


PLATE  VIII 


Fig.  1.     Refugee  camp 


Fig.  2.     Austrian  prisoners  after  being  bathed  and  disinfested 


PLATE  IX 


THE.  SERBIAN  EPIDEMIC  29 

In  view  of  the  immense  amount  of  time  and  work  that  has 
been  given  to  the  subject  of  the  construction  of  disinfestors 
since  the  Serbian  epidemic,  and  the  number  of  improved  types 
that  have  been  devised,  a  detailed  description  today  of  many 
of  the  makeshift  types  then  employed  is  hardly  justified.  Nut- 
tall  ^  has  recently  collected  from  the  literature  descriptions  of 
many  of  the  important  modern  British  and  some  of  the  Ger- 
man types,  and  therefore  these  need  not  be  described  here.  A 
few  of  those  employed  in  Serbia,  however,  may  be  mentioned 
in  the  present  article  in  order  to  demonstrate  what  can  be  ac- 
complished by  such  methods. 

The  most  crude  and  primitive  type  of  disinfestor  employed 
by  the  Serbian  people  was  made  by  digging  holes  upon  sloping 
ground  for  ovens  and  lining  them  with  bricks  or  stones.  In 
these  ovens  fires  were  lighted  and  the  opening  closed  by  a 
wooden  cover,  or  by  a  metal  one  if  metal  was  available.  After 
a  short  time  the  fire  was  scraped  out  and  the  clothing  to  be  dis- 
inf ested  placed  in  the  oven  on  a  grating  and  the  opening  again 
closed  with  the  cover.  The  Serbians  became  very  expert  in 
judging  the  degree  of  heat  requisite  to  kill  the  lice  and  their 
ova  and  yet  not  sufficient  to  injure  the  clothing  by  burning,  by 
placing  a  piece  of  white  paper  in  the  oven  and  removing  the 
clothes  when  the  paper  showed  the  first  tinge  of  turning  yellow 
from  the  heat.  Doubtless  some  of  my  readers  will  smile  at  this 
crude  method  of  disinfestation,  but  a  very  important  principle 
in  connection  with  the  suppression  of  the  epidemic  was  in- 
volved by  such  a  practice.  It  demonstrated  that  individuals 
who  would  really  undertake  to  carry  out  disinfestation  in  this 
patient  manner  above  described,  and  under  such  obvious  diffi- 
culties, were  interested  in  protecting  themselves  from  the  dis- 
ease and  thus  in  putting  down  the  epidemic.  Large  brick  or 
concrete  ovens  with  double  walls  of  a  single  brick  in  thickness 
between  which  hot  air  circulated  were  constructed  and  used 
extensively  in  many  of  the  smaller  villages.  In  these  the  in- 
fected clothing  was  loosely  placed  or  hung  upon  frames.  These 

^  Nuttall:  Parasitology,  1918,  x,  435. 


30  TYPHUS  FEVER 

disinfestors,  while  they  were  obviously  not  entirely  satisfactory, 
nevertheless  usually  accomplished  in  a  crude  way  the  desired 
purpose. 

Another  type  of  disinfestor  that  was  introduced  into  Serbia 
by  Colonel  Hunter  and  Colonel  Stammers,  and  employed  par- 
ticularly by  them  in  the  work  of  their  unit  at  Kraguevatz  and 
Mladenovac,  was  termed  "the  Serbian  barrel."    The  top  and 
bottom  of  a  barrel  was  knocked  out  and  a  grated  wooden  bot- 
tom and  a  flat  wooden  lid  provided.  A  short  trench  was  dug  in 
the  ground  which  would  accommodate  a  shallow  circular  metal 
tank  or  boiler  with  sufficient  space  for  a  fire  beneath.    The 
metal  boiler  was  placed  on  two  iron  bars  resting  upon  the  sides 
of  the  trench,  and  it  was  constructed  of  the  same  diameter  as 
the  bottom  of  the  barrel  which  rested  upon  it.  To  complete  the 
fireplace  in  which  wood  or  coal  was  used,  a  chimney  was  some- 
times placed  at  the  further  end  of  the  trench.  After  the  fire  was 
lighted  the  clothes  were  placed  in  the  barrel  and  the  cover  held 
down  by  a  few  stones  during  the  process  of  disinfesting.    As 
Nuttall  has  remarked,  this  arrangement  might  serve  as  a  make- 
shift but  it  has  drawbacks  which  need  not  be  emphasized. 
However,  as  I  have  pointed  out,  it  was  necessary  in  Serbia  to 
employ  all  possible  makeshift  methods.     While  the  barrel 
method  of  disinfestation  was  nevertheless  moderately  satisfac- 
tory for  the  individual,  it  was  fouTid  to  be  more  desirable  to 
construct,  whenever  possible,  stationary  and  permanent  de- 
lousing  stations  where  a  larger  number  of  people  could  be  dealt 
with.  Disinfestation  of  clothing  by  hot  fiatirons  was  employed 
very  little,  if  at  all,  in  Serbia. 

For  the  disinfestation  of  very  large  numbers  of  people  and 
their  clothing  in  a  short  space  of  time,  the  establishment  of  sani- 
tary trains  was  found  to  be  a  particularly  efficacious  method. 
The  disinfection  of  railroad  freight  cars  and  of  clothing  and 
blankets  in  them  by  steam  from  the  engine  in  connection 
with  the  suppression  of  epidemic  diseases  had  been  em- 
ployed in  Manchuria  in  1910  and  later  in  Germany,  and  freight 
cars  arranged  as  steam  disinfestors  were  known  to  be  in  use  in 
Germany  early  in  the  year  1915.    The  efficacy  of  the  sanitary 


Figs.  1  and  2.     Disinfecting  unit  in  charge  of  Dr.  F.  Gruver 


PLATE  XI 


THE  SERBIAN  EPIDEMIC  31 

disinfesting  train  units  we  employed  in  Serbia  was,  however, 
due  particularly  to  the  chief  engineer  of  the  Serbian  railway 
service  who  displayed  considerable  ingenuity  in  directing  the 
conversion  of  the  cars  for  this  purpose.  As  employed  by  us  in 
Serbia  these  sanitary  train  units  consisted  of  three  cars,  one  of 
which  was  occupied  by  a  large  engine  boiler  for  supplying  the 
steam;  a  second  car,  a  large  refrigerator  one,  was  made  air 
tight,  felt  being  placed  at  the  edges  of  the  side  door,  and  a  con- 
necting steam  pipe  was  so  arranged  that  steam  from  the  boiler 
could  be  turned  into  it  under  low  pressure,  the  ordinary  sys- 
tem of  pipes  in  the  roof  of  these  cars,  finely  perforated,  being 
also  thus  connected  up  with  the  boiler  engine,  the  steam  pass- 
ing from  these  fine  perforations  downward  and  through  the 
car.  The  clothing  was  hung  loosely  in  the  car  on  wire  suspended 
from  hooks.  Both  lice  and  ova  on  the  clothing  were  killed  in  a 
very  few  minutes  in  this  manner,  as  was  shown  by  repeated 
tests  carried  out  by  Dr.  Thomas  Jackson,  Chief  Sanitarian  of 
the  American  Red  Cross  Commission.  In  a  third  large  car 
shower  baths  were  constructed  with  a  reservoir  for  water 
above.  These  sanitary  trains  were  run  upon  railroad  sidings 
and  large  tents  were  erected  near  them.  The  people  marched 
to  the  tents,  several  hundred  at  a  time.  Usually  their  hair 
was  clipped,  and  then,  after  undressing,  their  clothing  was 
placed  in  the  steam  sterilizing  car.  They  next  passed  to  the 
car  in  which  the  shower  baths  were  placed,  and  after  a  thor- 
ough scrubbing  with  soap  and  water  here,  they  were  sprayed 
with  kerosene  as  an  additional  precaution  for  killing  the 
vermin  and  then  received  either  sterilized  clothing  or  new 
clothing. 

While  these  units  could  bathe  and  disinfest  the  clothing  of  a 
very  large  number  of  people  in  a  short  space  of  time,  there  are 
so  many  towns  and  villages  away  from  the  railway  in  Serbia 
that  other  means  had  to  be  devised  in  caring  for  the  people  in 
these  localities.  In  those  towns  and  villages  away  from  the 
railway,  as  well  as  in  the  large  cities,  permanent  bathing  and 
disinfesting  plants  were  constructed  and  regular  arrangements 
made  for  bathing  the  people  by  districts,  different  hours  being 


32  TYPHUS  FEVER 

arranged  for  the  men,  women,  and  children.  Buildings  such  as 
factories,  warehouses  and  breweries,  and  wherever  facilities  for 
obtaining  steam  were  available,  were  particularly  employed  in 
forming  delousing  centres.  Where  no  buildings  existed  which 
were  suitable  for  conversion  into  such  plants,  these  were 
constructed  of  rough  boards  or  of  bricks,  Austrian  prisoners 
being  employed  for  such  construction.  An  attempt  was  made 
to  arrange  for  a  disinfesting  plant  of  some  nature  in  every 
town.  All  the  available  Turkish  baths  were  used  in  this  con- 
nection. 

Both  the  plan  of  the  station  and  the  mode  of  procedure 
varied  with  the  facilities  available  in  the  locality,  and  as  to 
whether  there  were  laundry  facilities  at  hand  or  an  existing 
bathing  establishment,  or  whether  shower  baths  had  to  be 
erected.  In  the  hospitals  tub  baths  as  well  as  shower  baths 
were  particularly  employed,  the  tubs  and  much  of  the  piping 
necessary  for  the  shower  baths  having  been  brought  from 
America.  These  bathing  and  disinfesting  plants  were  usually 
arranged  so  that  the  infected  individuals  entered  at  one  side 
and  emerged  from  the  other  after  disinfestation.  There  was  a 
room  for  undressing  and  another  for  dry  disinfestation,  or  a 
shelter  under  which  a  steam  autoclave  was  placed  and  where 
the  clothing  was  treated;  a  room  for  bathing,  a  room  where  the 
individuals  were  sprayed  with  petroleum  or  sponged  with  car- 
bolic solution,  and  another  where  their  clean  clothing  was  re- 
ceived and  where  dressing  was  accomplished.  Sometimes  tents 
were  used  for  the  requisite  shelter. 

Whenever  steam  was  available  or  a  spare  boiler  could  be 
found,  which  could  be  put  into  use,  it  was  employed  for  disin- 
festing clothing.  Where  steam  was  not  obtainable  brick  ovens 
were  usually  constructed  and  the  clothing  disinfested  in  these. 
Indeed  existing  brick  kilns  were  sometimes  used  for  this  pur- 
pose where  available. 

For  the  reason  that  so  many  perfected  delousing  stations 
have  since  been  described,  those  constructed  in  Serbia  are  also 
not  considered  in  greater  detail. 


Fig.  1.    Steam  bathing  and  disinfesting  unit  in  charge  of  Dr.  T.  W.  Jackson 


Fig.  2.     Men  leaving  tent  before  bathing 


PLATE   XII 


Fig.  1.     Leaving  bath 


Fig.  2.    Returning  to  dressing  tent 


PLATE  XIII 


Fig.  1.     Construction  of  delousing  plant  with  Austrian  prison  labor 


Fig.  2.    Bathing  and  disinfesting  unit  in  charge  of  Dr.  George  C.  Shattuck 


PLATE  XIV 


P3 
O 

O 
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< 
o 


THE  SERBIAN  EPIDEMIC  33 

As  all  the  hospitals  were  infected,  it  was  necessary  systemat- 
ically to  disinfest  these.  The  patients  were  first  removed  from 
the  wards  and  were  placed  upon  a  scrubbing  board  where  they 
were  scrubbed  with  soap  and  water  and  afterwards  bathed 
with  dilute  carbolic  solution.  They  then  received  clean  cloth- 
ing and  were  placed  in  a  ward  which  had  previously  been 
cleaned  and  disinfested.  The  wards  after  being  sealed  were 
primarily  disinfested  by  sulphur  fumigation  in  order  to  de- 
stroy the  vermin.  Then  the  beds  were  taken  down  and  after 
scrubbing  with  soap  and  water  were  treated  with  carbolic  acid 
solution. 

The  mattresses  and  blankets,  when  there  were  any,  were 
steamed,  and  the  sheets  and  other  bed  clothing  boiled.  The 
floors  and  walls  were  often  scrubbed  or  sprayed  with  carbolic 
acid  or  bichlorid  of  mercury  solution.  In  addition  the  interior 
of  many  of  the  wards  was  whitewashed. 

Every  precaution  was  taken  to  protect  the  men  working  in 
infected  places  from  contracting  infection  by  insisting  upon  the 
use  of  a  proper  uniform.  The  Austrian  prisoners  were  largely 
employed  in  all  this  work,  and  as  many  of  them  had  already 
suffered  from  an  attack  of  typhus  and  were  therefore  immune, 
they  were  often  of  particular  value. 

A  uniform  which  was  found  to  be  suitable  for  nurses  and  sani- 
tary and  medical  officers  consisted  of  a  one-piece  garment,  the 
stockings  and  trousers  combined,  to  be  worn  preferably  under 
the  outer  clothing.  A  satisfactory  uniform  should  include  in 
addition  high  boots  or  shoes,  the  shoes  so  constructed  as  to  pre- 
vent the  entrance  of  pediculi  where  they  are  laced.  A  wide  strip 
of  adhesive  plaster  should  be  lightly  placed  around  the  leg  over 
the  top  of  the  shoe  or  boot  to  close  the  opening.  Rubber  gloves 
should  be  worn  when  handling  infested  individuals  or  clothing, 
and  there  should  be  another  strip  of  adhesive  plaster  around 
the  top  of  each  rubber  glove  to  prevent  the  ingress  of  the  lice. 
It  is  advisable,  for  women  at  least,  to  wear  a  closely  fitting 
headdress.  The  uniform  in  general  should  obviously  serve  to 
close  as  completely  as  possible  all  openings  of  the  garments  and 
thus  prevent  access  of  lice  to  the  skin.   Those  who  come  into 


34  TYPHUS  FEVER 

very  close  contact  with  the  patient,  and  particularly  those  who 
examine  the  throats  of  patients,  until  we  know  more  about  the 
methods  of  transmission  of  the  disease,  should  wear  a  simple 
mask  of  gauze  over  the  mouth  and  nostrils,  the  ends  being  tied 
behind  the  neck.  During  the  recent  epidemic  of  typhus  fever  in 
Serbia  such  a  uniform  as  above  described  was  frequently  em- 
ployed, and  some  of  the  physicians  employed  the  simple  mask 
described.  When  traveling  it  is  always  desirable  to  have  with 
one  a  folding  rubber  bathtub  and  a  small  supply  of  powdered 
naphthalene. 

In  the  anti-typhus  campaign  in  Serbia,  heat,  whenever  it 
could  be  employed,  was  considered  by  far  the  most  satisfactory 
means  for  the  destruction  of  lice  and  their  ova.  Although  cer- 
tain experiments  seem  to  show  that  the  virus  of  typhus  fever  is 
destroyed  by  a  temperature  of  55°  C.  for  fifteen  minutes,  and 
that  both  lice  and  their  ova  are  killed  by  dry  heat  at  55°  C. 
within  fifteen  minutes,  and  also  by  water  heated  to  55°  C. 
within  fifteen  minutes,  in  our  work  in  the  Serbian  epidemic, 
when  dry  heat  was  used  and  thermometers  were  available  to 
register  it,  a  temperature  of  about  60°  C.  for  fifteen  minutes  was 
regarded  as  a  safer  standard  to  assume  for  routine  practice  in 
connection  with  the  delousing  of  clothing  and  blankets.  When 
steam  was  available  for  disinf estation  it  was  the  custom  to  sub- 
mit articles  to  a  temperature  of  100°  C.  for  not  less  than  fifteen 
minutes,  usually  for  half  an  hour,  in  order  to  allow  the  steam  to 
thoroughly  penetrate  all  parts  of  the  clothing.  Fur  coats  and 
shoes  are  obviously  likely  to  be  ruined  by  steam  disinfection. 
However,'  hot  air  at  60°  C.  for  half  an  hour  does  not  injure 
either  furs  or  shoes  if  they  are  dry  before  being  heated  to  such 
a  temperature.  Furs  may  also  be  disinfested  by  carbon  di- 
sulphid,  but  this  is  not  recommended  for  general  use  and  was 
not  employed  in  Serbia.  Shoes  may  also  be  disinfested  with 
petroleum. 

A  great  many  chemical  substances  have  been  recommended 
for  destroying  lice  and  their  ova.  Those  particularly  employed 
in  our  anti-typhus  campaign  were  petroleum,  phinotos  oil  (a 
lysol-cresol  preparation),  sulphur,  and  to  a  less  extent  crude 


Figs.  1  and  2.     Prepakation  and  disinfection  of  hospital,  wards; 

UNIT  IN   CHARGE    OF   Dr.  FrANCIS   B.  GrINNELL 


PLATE  XVI 


Fig.  1.     Typhus  ward  atter  cleaning  and  disinfecting 


Fig.  2.     Antimalarial  section  at  work  in  Macedonia 


PLATE  XVII 


THE  SERBIAN  EPIDEMIC  35 

naphthalene  and  benzene.  Spraying  with  petroleum  from  a 
fine  spray  was  rather  generally  employed  after  bathing.  No 
injurious  effects  were  observed,  and  it  did  not  seem  to  cause 
much  dermatitis  in  the  Serbian  people.  Petroleum  often  ap- 
pears to  kill  lice  within  a  minute,  and  does  kill  them  almost 
invariably  within  two  or  three  minutes.  The  ova  sometimes 
survive  for  a  longer  period.  Some  laboratory  experiments  since 
performed  by  Nuttall  ^  seem  to  show  that  nits  are  sometimes 
not  killed  with  petroleum  in  twenty  minutes.  In  this  connec- 
tion the  chemical  composition  of  the  petroleum  must  be  con- 
sidered. The  petroleum  largely  used  in  Serbia  for  disinfestation 
was  brought  from  the  United  States.  Obviously  a  disinfestant 
may  be  shown  by  occasional  laboratory  experiments  not  to 
destroy  all  of  the  ova  or  lice  under  the  conditions  of  the  experi- 
ment, and  yet  it  may  be  a  disinfestant  of  considerable  practical 
value.  Moreover,  the  very  extensive  practical  use  to  which 
petroleum  was  put  in  Serbia  in  connection  with  delousing 
enormous  numbers  of  people  has  shown  it  to  be  a  very  satis- 
factory disinfestant  in  connection  with  an  epidemic  of  typhus. 
Experimental  work  on  the  subject  during  the  war  does  not 
appear  to  have  demonstrated  a  more  valuable  and  more  prac- 
tical disinfestant  for  the  purpose  for  which  it  was  employed  in 
Serbia.^  Phinotos  oil  was  particularly  employed  in  the  hos- 
pitals in  a  strength  of  about  2.5  per  cent  for  spraying  or  washing 
the  bodies  of  patients  after  bathing  them.  Both  ova  and  lice  are 
usually  destroyed  by  this  strength  of  the  solution  within  ten 
minutes.  This  preparation  in  stronger  solution,  5  per  cent,  was 
also  employed  occasionally  for  disinfesting  linen  and  for  disin- 
fecting the  walls  and  floors  of  the  houses  in  which  many  cases  of 
typhus  had  occurred,  or  in  the  hospital  wards  where  patients 
were  present.  Crude  carbolic  acid  was  sometimes  employed  in 
disinfesting  beds.  Wards  in  hospitals  and  houses  regarded  as 
badly  infected  were  first  disinfested  by  sulphur  fumigation. 

1  Nuttall:  loc.  cit. 

2  Castellani  and  Jackson,  from  Jour.  Trop.  Med.,  1915,  xviii,  253.  Kerosene  has 
also  been  employed  with  excellent  results  for  disinfestation  by  the  American  Public 
Health  Service,  Hicks,  Am.  Jour.  Pub.  Health,  1917,  vii,  628;  also  Cumming,  Jour.  Am. 
Med.  Assn.,  1917. 


36  TYPHUS  FEVER 

Among  the  American  Sanitary  Commission  were  a  number  of 
men  ^  who  had  a  very  wide  experience  in  the  use  of  sulphur  with 
General  Gorgas  in  his  campaign  against  yellow  fever  in  Pan- 
ama. All  the  necessary  appliances  including  the  sulphur  itself, 
alcohol,  pots  for  burning,  paper  and  paste  for  sealing,  buckets 
for  mixing  the  paste,  brushes,  etc.,  were  brought  in  enormous 
quantities  from  the  United  States.  The  item  of  sulphur  alone 
amounted  to  100  tons. 

Sulphur  fumigation  in  the  disinf estation  of  potentially  infec- 
tive houses  and  wards  during  an  epidemic,  on  the  whole,  is 
probably  the  safest  and  most  satisfactory  disinfestant  for  gen- 
eral employment  at  our  disposal.  If  employed  thoroughly  and 
in  the  proper  manner  the  adult  lice  are  destroyed,  and  although 
in  a  number  of  experiments  in  which  sulphur  dioxid  has  been 
employed,  all  the  ova  have  not  been  destroyed,  nevertheless 
the  chance  that  in  disinfesting  a  room  during  an  epidemic  the 
few  surviving  ova  are  infected  and  will  later  develop  and  still 
transmit  the  infection,  would  appear  to  be  rather  remote. 
Moreover,  there  is  no  definite  proof  that  hereditary  transmis- 
sion of  the  typhus  virus  occurs  in  the  louse,  and  the  most 
reliable  recent  evidence  is  opposed  to  this  idea. 

If  the  room  is  large  and  is  not  tightly  sealed  and  rendered 
approximately  air-tight,  the  amount  of  sulphur  dioxid  gas 
generated  must  of  course  be  increased  and  the  period  of  ex- 
posure prolonged.  In  Serbia,  for  'general  disinfestation  by  sul- 
phur fumigation,  not  less  than  five  to  eight  pounds  of  sulphur 
were  employed  per  1000  cubic  feet,  the  room  or  ward  being 
carefully  sealed  up  for  a  period  of  not  less  than  twelve  to 
twenty-four  hours,  the  time  varying  according  to  the  nature  of 
the  space  to  be  disinfested.  Sulphur  has  been  used  satisfac- 
torily for  disinfestation  during  the  war,  particularly  in  the 
French  and  ItaHan  armies,  and  in  the  German  army. 

Crude  naphthalene  was  employed  in  finely  powdered  form 
for  individual  prophylaxis.  It  was  found  convenient  to  carry 
the  naphthalene  about  with  one  in  a  bottle,  and  it  was  often 
dusted  over  the  underclothing,  particularly  after  inspection  of 

1  Drs.  Jackson,  Caldwell,  Gruver,  Colonel  Gale  and  others. 


THE  SERBIAN  EPIDEMIC  37 

prison  camps  and  other  groups  of  lousy  men;  also  over  the 
sheets  and  pillows  in  hotels  at  night.  Naphthalene,  from  a 
practical  standpoint,  must  also  be  regarded  of  considerable 
value  as  a  disinfestant  for  lice,  though  it  is  well  known  that  it  is 
not  an  absolutely  reliable  one,  and  that  it  is  dangerous  to  de- 
pend too  much  upon  it.  Bichlorid  of  mercury  in  1 :  500  or 
1:1000  solution  was  occasionally  employed  in  cleaning  hos- 
pitals. It  is  known  that  it  is  not  very  reliable  for  disinfesta- 
tion  in  connection  with  lice,  as  lice  sometimes  survive  for  more 
than  an  hour  upon  surfaces  upon  which  a  solution  of  1 :  2000 
or  even  1:  1000  of  bichlorid  of  mercury  has  been  previously 
sprayed. 

A  great  deal  of  work  in  connection  with  other  infectious  dis- 
eases was  also  carried  out  in  Serbia.  As  cholera  had  occurred  in 
places  along  the  border  between  Serbia  and  Austria  it  was 
deemed  advisable  to  perform  vaccination  against  this  disease, 
and  so  vaccination  trains  and  parties  were  also  established 
which  went  about  the  country  with  the  doctors  and  assistants, 
who  inoculated  thousands  of  people  daily.  Vaccination  against 
cholera  and  typhoid  fever  was  made  compulsory  in  Serbia.  At 
first  my  own  method  of  vaccination  against  cholera  was  em- 
ployed, as  it  has  the  advantage  of  only  requiring  a  single 
inoculation.  Later  on  typhoid  and  paratyphoid  fever  became 
prevalent  and  a  combined  vaccine  against  all  three  of  these 
diseases  was  manufactured  in  our  laboratories  in  Serbia  by  the 
method  of  Professor  Aldo  Castellani  and  sent  throughout  the 
country  for  use. 

Dr.  Castellani  was  placed  in  entire  charge  of  the  preparation 
of  the  vaccines.  No  cases  of  cholera  occurred  in  Serbia  during 
1915.  The  water  supply  of  many  of  the  towns  was  also  greatly 
improved,  and  artesi^m  wells  were  bored  in  a  number  of  in- 
stances where  the  water  of  the  vicinity  had  been  condemned  as 
unsafe  after  it  had  been  examined  systematically  in  our  labora- 
tories, apparatus  for  boring  these  wells  having  been  brought 
from  the  United  States.  In  fact,  a  systematic  bacteriological 
examination  of  local  water  supplies  was  one  of  the  tasks  which 
was  undertaken  by  our  laboratories. 


38  TYPHUS  FEVER 

An  important  problem  in  the  reduction  of  the  amount  of 
typhoid  fever  and  the  prevention  of  cholera  was  the  disposal  of 
human  excreta,  and  a  large  number  of  sanitary  and  fly-proof 
latrines  were  constructed  throughout  the  country,  particularly 
about  barracks,  hospitals,  etc.  In  many  cases  the  cesspools  be- 
came filled  to  overflowing,  and  there  was  not  a  sufficient  num- 
ber of  hydraulic  pumps  in  Serbia  to  .empty  a  quarter  of  them. 
Our  Red  Cross  immediately  supplied,  upon  my  request,  a  large 
number  of  these  pumps.  The  construction  of  filter  beds  for 
purification  of  sewage  was  also  undertaken  in  a  number  of 
places,  and  the  sanitary  condition  of  some  of  the  cemeteries, 
where  there  were  numerous  shallow  pits  in  which  twenty  to 
thirty  bodies  at  a  time  had  been  buried  and  insufficiently 
covered  with  earth,  was  improved. 

A  campaign  for  the  destruction  of  the  breeding  places  of  flies, 
in  connection  particularly  with  the  spread  of  typhoid  and 
cholera,  and  of  mosquitoes,  in  relation  to  the  spread  of  malaria 
in  southern  Serbia,  was  also  undertaken. 

In  regard  to  the  course  of  the  epidemic  of  typhus  in  Serbia 
and  the  influence  of  the  anti-typhus  campaign  upon  it,  it  is 
interesting  to  refer  briefly  to  the  history  of  the  disease  in 
previous  epidemics. 

Summary  of  Previous  Epidemics 

Hirsch  ^  states  that  the  history  of  typhus  is  written  in  those 
dark  pages  of  the  world's  history  which  tell  of  the  grievous 
visitations  of  mankind  by  war,  famine,  and  misery  of  every 
kind.  In  every  age  as  far  back  as  the  historical  inquirer  can 
follow  the  disease  at  all,  typhus  is  met  with  in  association  with 
the  saddest  misfortunes  of  the  populace.  From  the  writings  of 
Corradi  we  know  that  typhus  fever  was  epidemic  in  Italy  in 
1505,  and  shortly  afterwards  spread  from  there  all  over  Europe. 
The  disease  was  described  more  accurately  by  Fracastori  in 
1533,  and  from  this  date  onward  its  history  can  be  more  readily 
traced.  It  had  evidently  also  prevailed  extensively  at  an  earlier 
time   and  with  great   severity   among  the   Castilian  troops 

1  Hirsch:  Handbook  of  Geographical  and  Historical  Pathology,  1883/ i,  545. 


> 
X 

w 


Pi 

< 

a 

< 
o 

K 
O 


Fig.  1.     Filled  cesspool 


Fig.  2.     A  typical  Serbian  town  after  eradication  of  typhus 


PLATE  XX 


THE  SERBIAN  EPIDEMIC  39 

shortly  after  the  siege  of  Granada.  Later  (1557)  it  became 
known  in  Spain  under  the  name  of  el  tabardillo  (the  much 
dreaded  red  cloak);  and  in  this  country  there  were  repeated 
epidemics.  In  a  third  epidemic  in  Italy  in  the  second  half  of  the 
sixteenth  century,  it  is  said  to  have  destroyed  more  than  one 
million  people  in  Tuscany.  In  1566  it  became  epidemic  in  the 
army  of  Maximilian  II  of  Hungary  and  extended  its  ravages 
again  over  Europe,  continuing  for  more  than  twenty-one  years. 
In  the  seventeenth  century  typhus  was  again  one  of  the  dis- 
eases which  caused  the  highest  mortality.  So  great  were  the 
miseries  engendered  by  it  and  by  the  other  events  in  connection 
with  the  Thirty  Years  War,  that  Haeser,  writing  of  this  period 
with  reference  to  districts  formerly  well  populated,  says  that 
one  could  wander  for  miles  without  seeing  a  living  soul,  only 
dead  bodies  decomposing  and  partially  devoured  by  wolves, 
dogs,  and  vultures,  for  want  of  a  decent  burial.  Towards  the 
close  of  this  century  Morton  implies  that  practically  every  hos- 
pital in  England  was  filled  with  typhus  victims.  The  eight- 
eenth century  saw  no  abatement  of  typhus  epidemics,  and 
there  is  scarcely  a  year  during  this  century  that  one  may  not 
find  references  to  epidemics  of  it. 

Hirsch,  however,  distinguishes  four  periods  during  which  the 
disease  was  excessively  prevalent;  the  first  period  was  a  con- 
tinuance of  the  outbreaks  which  had  occurred  in  Germany  and 
in  Austria-Hungary  as  a  result  of  the  wars  waged  in  those 
countries.  The  epidemics  died  out  about  the  year  1720.  Dur- 
ing the  second  period,  1734-44,  the  disease  ravaged  Central 
and  Eastern  Europe.  It  was  first  noticed  among  the  Polish 
troops  engaged  in  the  war  of  the  Polish  succession.  It  spread 
throughout  Russia,  Prussia,  Silesia,  and  the  central  German 
states  and  the  Netherlands.  The  English  and  French  troops 
engaged  in  these  wars  were  also  affected.  The  third  period 
lasted  from  1757-75.  It  owed  its  origin  to  the  Seven  Years  War, 
starting  in  1757  between  England  and  France.  The  epidemic 
began  in  Prussia,  extended  all  over  Germany,  and  then  spread 
to  France  and  Spain.  In  1764  and  1767  extensive  epidemics 
occurred  over  most  of  Italy,  it  is  said  as  a  result  of  a  total  failure 


40  TYPHUS  FEVER 

of  crops  in  each  case.  The  fourth  and  most  extensive  period 
beg^n  in  1789  in  France  during  the  Revolution,  and  from  there 
spread  over  the  whole  of  Europe.  The  disease  persisted  in 
epidemic  form  throughout  the  duration  of  the  Napoleonic  wars, 
and  did  not  begin  to  subside  until  the  conclusion  of  peace  in 
1815,  after  the  Battle  of  Waterloo.  This  was  said  to  be  the 
severest  epidemic  of  typhus  fever  ever  recorded  on  the  con- 
tinent. The  disease  was  always  most  severe  in  those  places 
where  the  various  battles  and  sieges  occurred,  but  it  spread  to 
many  places  far  removed  from  the  sites  of  war.  The  general 
poverty  and  distress,  the  results  of  war,  evidently  aided  greatly 
in  the  spread  of  the  disease  in  these  localities. 

After  this  severe  epidemic  over  the  whole  of  Europe  no  gen- 
eral epidemic  occurred  until  the  years  1846  and  1847,  when 
typhus  fever  became  widespread  again  over  the  entire  con- 
tinent; however,  from  1816  to  1873  in  Italy  there  were  fifty-one 
epidemics,  and  in  France,  there  were  sixteen. 

In  England  there  were  definite  references  to  epidemics  from 
1643.  According  to  Creighton,  in  1694  the  fever  deaths  in  Lon- 
don were  5036.  In  1741,  during  a  general  epidemic  of  typhus, 
there  were  7500.  Another  severe  epidemic  began  in  England  in 
1831,  and  continued  its  ravages  there  for  more  than  ten  years, 
being  at  its  worst,  however,  between  1837-42.  Another  serious 
epidemic  occurred  between  1862-69,  and  particularly  in  London 
between  1863-65.  In  England  and  Wales  during  the  period 
1869-83  there  were  23,702  deaths  from  typhus.  During  1884-98 
there  were  2249,  while  during  1899-1913  there  were  only  390. 

Ireland  had  long  been  infected  by  typhus,  and,  particularly 
from  1708,  this  country  was  ravaged  by  one  epidemic  after 
another.  At  the  beginning  of  the  eighteenth  century  the  popu- 
lation of  Ireland  was  estimated  at  about  seven  million,  and 
during  1846-47  the  number  of  sick  at  one  million,  about  one- 
seventh  of  the  population.  In  Dublin  alone  there  were  60,000 
cases  of  the  disease.  Since  1815,  apart  from  smaller  epidemics, 
the  disease  has  spread  widely  six  times,  the  epidemic  of  1846- 
48  above  referred  to  being  one  of  the  severest,  and  the  last  of 
these  six  severe  epidemics  being  from  1862-64. 


THE  SERBIAN  EPIDEMIC  41 

In  Mexico  the  disease  became  epidemic  in  1530,  shortly  after 
the  conquest.  Another  outbreak  occurred  in  1570,  being  said  to 
have  been  imported  from  Spain.  In  1734-36,  189,000  people 
are  reported  to  have  died  from  typhus  fever  in  Mexico.  There 
have  been  numerous  epidemics  during  the  nineteenth  century, 
one  of  the  most  serious  in  1861. 

In  the  United  States  and  Canada  typhus  also  prevailed  in 
certain  centers  in  the  early  years  of  the  nineteenth  century, 
and  there  were  severe  epidemics  following  the  Irish  immigra- 
tions in  1846  and  1847.  In  South  America  typhus  was  probably 
imported  from  Spain  to  Peru  at  a  very  early  period  where  it  was 
well  known  under  the  Spanish  name  of  tabardillo  in  1821,  1825, 
and  1846.  It  also  prevailed  in  Chili  at  the  same  period.  The 
Napoleonic,  Crimean,  Russo-Turkish,  and  recent  Balkan  wars 
have  all  been  accompanied  by  typhus.  Early  in  the  recent 
great  war,  typhus  appeared  in  Germany  among  the  Russian 
prisoners  of  war  in  Austria,  and  it  also  became  epidemic  among 
the  Turkish  troops  in  the  Erzeroum  district. 

It  has  not  been  my  intention  to  attempt  a  complete  sum- 
mary of  the  history  of  typhus  fever  in  this  Report,  but  merely 
to  cite  many  of  the  important  epidemics  in  order  that  it  may  be 
seen  that  in  earlier  years  the  disease  apparently  raged  almost 
unrestrictedly.  The  epidemics  often  continued  for  a  number  of 
years  at  a  time  and  were  not  limited  to  or  by  any  particular 
season. 

Hirsch  writes  that  out  of  147  epidemics  which  occurred  in  the 
temperate  and  cold  latitudes  of  the  eastern  and  western  hemi- 
spheres, and  of  which  we  have  accurate  data  as  to  the  time  of 
their  outbreak  and  their  course,  30  reached  their  acme  in 
spring,  28  in  winter  and  spring,  21  in  spring  and  summer,  19  in 
summer  and  autumn,  18  in  autumn,  17  in  summer,  and  14  in 
autumn  and  winter.  He  concludes  that  even  if  there  can  be  no 
doubt  that  the  maximum  of  typhus  cases  falls  distinctly  in  the 
colder  months  (winter  and  spring)  yet  it  is  proved  that  typhus 
is  quite  independent  of  season  and  weather  in  its  development 
and  epidemic  diffusion;  that  neither  the  upper  nor  lower  ex- 
tremities of  temperature  or  moisture  can  further  or  hinder  the 


42  TYPHUS  FEVER 

disease  in  its  breaking  out  and  progress,  nor  any  other  condi- 
tion of  weather  exert  a  perceptible  influence  in  these  respects. 
It  is  in  this  sense  that  almost  all  the  authorities  express  them- 
selves. 

Osier  has  remarked  that  the  gradual  disappearance  of  the 
disease  in  Great  Britain  and  on  the  continent  has  been  one  of 
the  great  triumphs  of  sanitation  and  this  also  proved  to  be  the 
case  in  connection  with  the  epidemic  in  Serbia.  It  will  be  re- 
called that  this  epidemic  of  typhus  fever  was  the  first  extensive 
and  serious  one  to  occur  since  the  demonstration  of  the  method 
of  the  transmission  of  this  disease  by  lice  in  1909-10.  It  should 
be  emphasized  that  the  efforts  of  all  of  the  physicians,  sani- 
tarians, nurses,  and  particularly  of  the  people  generally  in  Ser- 
bia being  directed  against  the  spread  of  the  disease  by  pediculi, 
the  suppression  of  the  epidemic  by  intensive  work  was  accom- 
plished within  a  period  of  six  months. 

Method  of  Transmission 

In  connection  with  the  Serbian  epidemic,  it  is  also  important 
to  refer  to  the  method  of  transmission  of  the  disease. 

As  long  ago  as  1876,  Murchison  suggested,  in  addition  to 
other  measures  in  connection  with  the  prevention  of  typhus, 
that  in  order  to  prevent  an  individual  from  acquiring  such 
infection,  it  was  necessary  to  protect  him  from  lice.  In  1903,  at 
the  International  Sanitary  Congress  held  in  Paris,^  Dr.  Cor- 
tezo  made  a  statement  based  upon  his  experiences  in  an  epi- 
demic at  Madrid  that  typhus  fever  is  transmitted  by  lice  and 
fleas,  but  no  data  of  speciflc  experiments  were  supplied  demon- 
strating these  facts.  It  has  been  for  a  long  time  a  well-recog- 
nized fact  that  epidemics  of  typhus  fever  and  of  relapsing  fever 
occur  side  by  side  and  under  similar  conditions,  and  the  close 
association  of  these  two  diseases  has  indeed  been  noted  since 
1739.  This  fact  and  the  work  carried  out  upon  relapsing  fever 
by  Sergent  and  Foley  ^  and  Mackie  ^  and  Smith  ^  suggested 

1  OflBcial  abstracts  of  Proceedings  of  the  Conference,  p.  343. 

2  Sergent  and  Foley:  Bull.  Soc.  de  path,  exot.,  1908,  i,  174. 

3  Mackie:  Brit.  Med.  Jour.,  1907,  ii,  1706. 

^  Smith:  Medical  Thesis  (London),  1909,  John  Bale  Sons  and  Danielson,  Ltd. 


THE  SERBIAN  EPIDEMIC  43 

that  lice  were  also  probably  the  transmitters  of  typhus  fever. 
However,  in  1909,  NicoUe  ^  working  in  Algiers  showed  by 
actual  experiments  that  the  chimpanzee  could  be  infected  with 
the  typhus  virus  by  the  injection  of  a  small  amount  of  blood 
from  a  human  active  case  of  the  disease.  He  then  showed  that 
lower  monkeys  could  be  similarly  infected  by  the  inoculation  of 
the  chimpanzee's  blood,  and  that  then  the  infection  could  be 
transmitted  from  monkey  to  monkey  by  means  of  the  bites  of 
infected  body  lice  (Pediculus  humanus  var.  corporis) .  This  work 
was  shortly  afterwards  confirmed  in  the  United  States  by 
Ricketts  and  Wilder  ^  and  by  Anderson  and  Goldberger,^  who 
also  showed  that  the  lower  monkeys  might  be  infected  directly 
with  human  typhus  blood  or  by  the  bites  of  lice  that  had  fed 
upon  human  cases  of  the  disease.  Later  it  was  shown  by  dif- 
ferent investigators,  Wilder,*  Goldberger,*  Prowazek,®  Sergent,^ 
and  Nicolle,^  that  the  disease  may  be  transmitted  to  monkeys 
by  inoculating  them  with  the  contents  of  crushed  lice  or  with 
faeces  of  infected  lice,  the  lice  or  their  faeces  becoming  capable 
of  conveying  infection  from  two  to  eleven  days  after  feeding 
upon  typhus  infected  blood,  and  the  blood  in  typhus  fever 
cases  being  found  infective  from  the  third  to  the  tenth  day  of 
the  attack.  A  few  experiments  which  have  been  undertaken 
with  bedbugs  and  fleas  seem  to  show  that  these  insects  do  not 
transmit  typhus  fever.  From  other  experimental  work  per- 
formed, first  by  Anderson  and  Goldberger  ^  and  more  recently 
by  Toepfer^*^  NicoUe  ^^  and  others,  and  from  observations  made 

^  Nicolle:  Compt.  rend.  Acad.  d.  sc,  Paris,  1909,  cxlix,  157;  Ann.  de  I'Inst.  Pasteur, 
1910,  xxiv,  243. 

2  Ricketts  and  Wilder:  Jour.  Am.  Med.  Assn.,  1910,  liv,  463;  Wilder:  Jour.  Infect. 
Dis.,  1911,  ix,  9. 

3  Anderson  and  Goldberger:  Pub.  Health  Rep.,  Wash.,  1910,  xxv,  177;  also  Bull.  Hyg. 
Lab.,  U.  S.  P.  H.  S.,  Wash.,  1912,  Bull.  No.  86,  p.  13. 

^  Wilder:  loc.  cit.,  1911. 

5  Goldberger:  Pub.  Health  Rep.,  Wash.,  1912,  xxvii,  297;  and  Bull.  Hyg.  Lab.,  U.  S. 
P.  H.  S.,  1912,  No.  86,  p.  37. 

6  Prowazek:  Berl.  klin.  Wchnschr,  1913,  1,  2037. 

'  Sergent,  Foley,  and  Vialatte:  Compt.  rend.  Acad.  d.  sc,  Paris,  1914,  clviii,  964. 
^  Nicolle,  Blanc,  and  Conseil:  ibid.,  clix,  661. 
8  Anderson  and  Goldberger:  loc.  cit.,  1912. 

10  Toepfer:  Deutsch.  med.  Wchnschr.,  1916,  xlii,  1251. 

11  Nicolle:  Bull,  de  I'Inst.  Pasteur,  1920,  xviii,  49. 


44  TYPHUS  FEVER 

by  Foster  in  the  Philippines  ^  it  seems  not  unhkely  that  Pedi- 
culus  capitis,  the  head  louse,  may  also  sometimes  transmit  the 
disease.  Further  experimental  work  on  this  question,  however, 
would  appear  desirable.  Nuttall  ^  apparently  inclines  to  the 
belief  that  Goldberger's  experiments  are  not  entirely  convinc- 
ing but  NicoUe^  states  that  P.  capitis  uasiy  convey  the  disease. 
It  has  also  been  suggested  that  infection  may  occur  in  man 
by  the  ova  of  infected  lice  being  rubbed  or  scratched  into 
abrasions  of  the  skin,  but  it  has  not  yet  been  definitely  demon- 
strated if  hereditary  transmission  of  the  typhus  virus  occurs  in 
lice,  the  evidence  on  this  question  being  contradictory. 

There  have  been  no  scientific  and  properly  controlled  actual 
experiments  performed  upon  human  beings  which  demonstrate 
that  typhus  is  transmitted  by  lice,  though  Moczutowski  in 
1900  and  Yersin  and  Vassal  ^  and  Ostero  ^  demonstrated  by 
human  experiment  that  the  disease  could  be  transmitted  by 
direct  injection  of  typhus  blood.  However,  in  a  few  instances 
in  which  accidental  infection  or  experiments  in  man  were  car- 
ried out  in  connection  with  transmission  by  lice,  the  evidence 
has  been  in  favor  of  the  view  that  the  transmission  of  typhus  is 
through  this  agency.  These  human  experiments,  however,  had 
not  been  adequately  controlled  as  is  evidenced  from  the  follow- 
ing summary  of  them.^ 

Sergent,  Foley,  and  Vialatte,^  trying  to  prove  the  transmis- 
sion of  recurrent  fever  by  the  louse,  made  lice  who  had  fed  on  a 
patient  of  recurrent  fever  bite  a  man.  Another  man  was  inocu- 
lated with  similar  lice,  and  still  another  with  eggs  from  such  lice. 
All  of  them  developed  typhus.  Sergent,  Foley,  and  Vialatte 
explained  this  by  assuming  that  the  patient  was  suffering  from 
typhus  at  the  same  time  or  was  already  infected  with  typhus. 
This  seems  not  unlikely,  as  it  is  well  known  that  both  of  these 

1  Foster:  Arch.  Int.  Med.,  1915,  xvi,  363. 

2  Nuttall:  Parasitology,  1917,  x,  52. 
^  Nicolle:  loc.  cit. 

^  Yersin  and  Vassal:  cited  by  Thoinot,  Paris  Med.,  1915,  Nos.  49-50,  p.  473. 
^  Ostero:  cited  by  Vincent  and  Muratet,  "Exanthematic  Typhus,"  Univ.  of  London 
Press,  1917,  p.  207. 

6  Banus:  Intern.  Jour.  Pub.  Health,  Geneva,  1920,  i,  69. 

^  Sergent,  Foley,  and  Vialatte:  Compt.  rend.  Acad.  d.  sc,  1914,  clviii,  964. 


THE  SERBIAN  EPIDEMIC  45 

diseases  occur  together  in  epidemic  form,  and  Kirkovic  and 
Alexieff  ^  have  reported  thirty-three  cases  in  which  both  dis- 
eases were  present  at  the  same  time,  and  they  state  that  in 
most  of  these  cases  the  recurrent  fever  appeared  first.  Another 
instance  of  transmission  to  man  is  reported  by  Ussher,^  who 
states  that  a  male  nurse  allowed  himself  to  be  bitten  by  an  in- 
fected louse  and  developed  typhus  in  five  days.  Nicolle,  Blanc, 
and  Conseil,^  tell  of  the  case  of  the  warder  in  the  penitentiary 
at  Tunis  who  caused  infected  lice  to  bite  one  of  two  workers 
coming  from  the  outside  and  with  no  contact  with  any  typhus 
patients.  The  bitten  man  developed  typhus  while  the  other 
did  not.  They  describe,  too,  another  case,  that  of  a  laboratory- 
assistant  who  was  bitten  accidentally  by  an  infected  louse  and 
developed  the  disease.  This  experimental  evidence  on  human 
beings  alone  of  transmission  of  typhus  by  lice  is  obviously  not 
strong  enough  to  be  entirely  convincing  and  does  not  exclude 
the  hypothesis  of  other  means  of  transmission. 

A  great  many  physicians  of  different  nationalities  have  died 
from  typhus  during  the  war  and  a  great  many  more  have  con- 
tracted the  disease.  In  many  instances  these  physicians  were 
thoroughly  cognizant  of  the  method  of  transference  of  the  dis- 
ease by  lice  and  of  the  precautions  to  be  taken  in  avoiding  such 
infection.  In  a  number  of  instances  where  particular  care  was 
taken  to  avoid  contamination  with  lice,  nevertheless,  infection 
with  typhus  followed.  For  this  reason  it  has  been  particularly 
urged  that  infection  sometimes  must  occur  in  man  by  another 
manner  than  through  the  agency  of  pediculi,  and  it  has  been 
suggested  that  the  droplet  method  of  infection  after  coughing 
might  sometimes  occur  in  this  disease.  It  is  recognized  that  in 
the  early  stages  of  iyphus  there  are  likely  to  be  inflammatory 
conditions  of  the  mouth,  nose,  and  throat.  A  number  of  in- 
stances have  been  recently  recorded  in  medical  literature  and 
evidence  given  which  is  sometimes  in  favor  and  sometimes  op- 
posed to  the  idea  of  the  possibility  of  droplet  infection  in  ty- 

1  Kirkovic  and  Alexieff:  Arch.  f.  Schiffs-  u.  Tropen-Hyg.,  xxii,  289. 

2  Ussher:  Med.  Rec,  1914,  Ixxxvi,  509. 

^  NicoUe,  Blanc,  and  Conseil:  Compt.  rend.  Acad.  d.  sc,  1914,  clix,  661;  Ann.  de 
I'Inst.  Pasteur,  1910,  xxiv,  261. 


46  TYPHUS  FEVER 

phus  fever.  As  yet  there  has  been  no  experimental  proof  that 
the  sputum  or  saliva  in  typhus  fever  contains  the  virus,  but  on 
the  other  hand  there  have  been  no  careful  experiments  per- 
formed upon  man  in  which  the  saliva  or  sputum  have  been  em- 
ployed for  infection.  Also,  even  if  typhus  may  sometimes  be 
transmitted  to  man  by  droplet  infection,  the  experimental 
proof  of  this  fact  might  be  very  difficult.  In  this  connection  we 
have  only  to  recall  the  negative  experiments  performed  upon 
man  by  Rosenau  and  his  associates  ^  in  connection  with  the 
transmission  of  influenza  by  the  sputum  and  by  droplet  infec- 
tion. It  must  be  borne  in  mind  that  the  virus  of  typhus  fever 
has  repeatedly  been  shown  to  be  present  in  the  blood;  that 
Moczutowski  inoculated  himself  in  this  manner  and  suffered  an 
attack  of  typhus  fever  after  an  incubation  period  of  18  days. 
Yersin  and  Vassal  also  inoculated  two  men  with  typhus  blood 
who  developed  typhus  after  14  and  21  days  respectively. 
While  the  experimental  transmission  of  typhus  infection  to 
monkeys  and  other  animals  is  certainly  sometimes  very  un- 
satisfactory,^ and  the  proof  that  the  infection  has  been  actually 
transmitted  not  always  definite  and  convincing  without  the 
most  minute  study,  nevertheless,  practically  all  such  transmis- 
sion experiments  in  animals  are  also  in  favor  of  the  view  that 
the  virus  of  tjrphus  is  present  in  the  circulating  blood  and  that 
the  blood  is  usually  infected  during  the  active  period  of  the 
fever.  As  the  virus  is  present  in  the  blood  it  would  not  be  sur- 
prising if  some  of  the  secretions  also  contained  it.  The  experi- 
ments recently  performed  on  man  in  demonstrating  the  method 
of  transmission  of  trench  fever  are  interesting  in  this  connec- 
tion.^ A  series  of  inoculations  in  man  with  urine  or  urinary 
sediments  and  with  saliva  or  sputum  from  typhus  cases  might 
give  further  information  on  this  question.  While  it  seems  evi- 
dent that  the  only  common  and  important  method  of  trans- 
mission of  typhus  is  through  the  louse,  and  that  epidemics  of 

1  Rosenau:  Jour.  Am.  Med.  Assn.,  1919,  Ixxiii,  311. 

2  See  in  this  connection,  Friedberger,  Ztschr.  f.  Immunitatsforsch.  u.  exper.  Therap., 
1920,  Ixxix,  125,  who  states  it  is  not  possible  to  infect  guinea  pigs  with  typhus  blood. 

^  Trench  Fever,  Report  of  Commission  Medical  Research  Committee,  American  Red 
Cross,  Oxford  University  Press,  1918,  p.  37. 


THE  SERBIAN  EPIDEMIC  47 

the  disease  are  due  to  this  method  of  transmission  alone,  never- 
theless, several  careful  observers  have  the  impression  that 
exceptionally  and  rarely  typhus  may  be  transmitted  to  those 
who  come  into  close  intimacy  and  contact  with  patients  by 
some  other  means.  In  cases  of  typhus  in  which  there  are 
abrasions  of  the  mucous  membranes  of  the  mouth,  nose,  and 
throat,  the  possibility  of  infection  through  coughing  should  be 
borne  in  mind.  A  number  of  observers  are  in  favor  of  this  idea. 
Thus  Kraus  believes  that  there  is  some  other  means  of  trans- 
mission than  by  the  body  louse,  and  states  that  this  was  the 
belief  of  all  the  Galician  doctors  who  based  their  views  on  the 
observation  that  if  the  rooms  containing  tjrphus  patients  were 
kept  well  ventilated,  no  infection  occurred  among  the  person- 
nel. Allan  ^  is  of  the  same  opinion  that,  if  a  person  not  pro- 
tected by  a  previous  attack  remains  some  time  in  a  close,  stuffy 
room  near  the  patient,  he  runs  the  risk  of  contracting  the  dis- 
ease although  no  lice  may  be  present.  Walter  ^  suggests  the 
danger  of  overlooking  such  a  possibility  and  describes  an  epi- 
demic which  he  could  not  entirely  explain  on  the  assumption  of 
transmission  by  the  louse.  Friedberger,^  in  his  account  of  the 
epidemic  in  Pomerania,  expresses  doubts  as  to  whether  the 
louse  is  the  real  carrier,  because  he  found  cases  that  he  could 
not  ascribe  to  louse  bites,  among  which  were  those  of  four 
doctors  who  developed  tj^phus  without  even  having  felt  a  louse 
bite,  and  that  of  a  lady  who  only  once  for  a  short  time  had 
entered  a  room  occupied  by  patients  in  order  to  give  them  some 
apples. 

The  idea  of  droplet  infection  is  also  supported  by  Rondke,* 
who  bases  it  on  the  evidence  of  the  case  of  one  nurse  who  de- 
veloped typhus  when  no  new  patients  had  been  admitted  for 
ten  days,  while  all  the  sick  people  were  free  from  lice.  She  had 
taken  very  carefully  all  the  precautions  advised,  but  did  not 
wear  a  mask.  A  similar  case  is  reported  by  Sellards  ^  and  Shat- 

1  Allan:  Brit.  Med.  Jour.,  1915,  ii,  841. 

2  Walter:  Berl.  klin.  Wchnschr.,  1915,  Hi,  851. 

^  Friedberger:  Ztschr.  f.  Hyg.  u.  Infectionskrankh.,  1918,  Ixxxvii,  475. 
^  Rondke:  Med.  Klin.,  1915,  p.  1152. 
^  Sellards:  Part  III  in  this  Report. 


48  TYPHUS  FEVER 

tuck  ^  in  Serbia  of  a  nurse  who  protected  herself  very  carefully, 
wearing  a  louse-proof  suit.  She  had  to  sponge  and  swab  the 
throat  of  a  very  severe  case  with  serious  lung  and  mouth  com- 
plications. The  patient  was  free  from  lice  but  coughing  fre- 
quently. The  nurse  developed  typhus  after  two  weeks.  Of  the 
same  opinion  are  Flueggi,  Gaertner,  Bujwid;  Kisskalt,  Uhlen- 
huth,  and  Stroklosinski,^  Larrieu  and  Delarde  and  d'Halluin. 
Delarde  and  d'Halluin  ^  believe  that  in  some  cases  of  typhus 
during  the  epidemic  they  studied  in  Germany,  droplets  of 
saliva  expelled  in  coughing  were  infectious,  and  when  inocu- 
lated to  the  mucosa  produced  the  disease.  They  also  report 
the  case  of  a  physician  who  was  found  to  be  free  from  lice  and 
yet  contracted  typhus.  One  should  not  dismiss  such  evidence 
with  the  mere  statement  that  the  small  larval  stages  of  lice  may 
well  escape  notice.  It  does  not  seem  entirely  improbable  that 
some  of  the  doctors  and  nurses,  who  came  repeatedly  into  very 
close  contact  with  typhus  cases  and  who  have  lost  their  lives 
from  this  disease  during  the  war,  contracted  the  infection  per- 
haps because  they  regarded  the  only  possible  means  of  trans- 
mission to  be  by  body  lice,  and  only  took  precautions  against 
this  means  of  infection.  That  typhus  may  be  sometimes  trans- 
mitted by  some  other  means  than  by  the  louse  is  a  view  held  by 
a  considerable  number  of  physicians  who  have  had  during  the 
war  an  unusual  experience  during  epidemics,  though  little  cre- 
dence is  given  to  this  idea  by  some  investigators  who  have  no 
such  experience  and  who  have  formed  their  judgment  that  the 
louse  is  the  sole  transmitter  from  the  louse  transmission  ex- 
periments recorded  in  the  literature. 

Granting  that  the  spread  of  the  disease  in  epidemics  is  due  to 
louse  transmission,  and  that  our  methods  in  combating  success- 
fully this  disease  in  epidemics  need  only  be  directed  against 
such  a  means  of  transmission,  nevertheless,  it  must  be  borne  in 

1  Shattuck,  G.  C. :  Harvard  Graduate  Magazine. 

2  Flueggi,  Gaertrier,  Bujwid,  Kisskalt,  Uhlenhuth,  and  Stroklosinski :  Med.  Klin., 

1915,  p.  586. 

2  Larrieu  and  Delarde  and  d'Halluin:  Bull,  et  mem.  Soc.  med.  d.  hop.  de  Paris, 

1916,  xxxii,  320. 


THE  SERBIAN  EPIDEMIC  49 

mind  that  this  does  not  exclude  exceptional  instances  of  infec- 
tion by  other  means. 

Typhus  fever  claims  more  victims  in  the  medical  profession 
than  any  other  epidemic  disease.  The  mortality  among  phy- 
sicians in  epidemics  is  generally  high.  Osier  states  in  a  period  of 
25  years  in  Ireland,  among  1230  physicians  attached  to  institu- 
tions, 550  died  of  typhus.  Minkine  reports  that  out  of  13  phy- 
sicians working  at  the  tjrphus  hospitals,  12  contracted  the 
disease,  and  6  of  them  died.  Butler  in  connection  with  his 
typhus  hospital  unit  states  that  of  6  physicians,  4  contracted  it 
and  2  died.  The  mortality  among  the  Serbian  physicians,  126 
out  of  350,  or  36  per  cent,  has  already  been  referred  to.  More- 
over, some  of  these  physicians  were  immune  from  previous 
attacks  contracted  before  this  epidemic.  Friedberger,^  in  re- 
porting an  epidemic  at  Schutzen  in  1915,  states  that  24  of  the 
doctors  were  attacked  and  14  died,  a  mortality  of  58  per  cent; 
that  of  332  nurses,  71  fell  ill  of  whom  15  died,  a  mortality  of 
21  per  cent;  at  the  same  time  the  disease  among  the  Russian 
prisoners  showed  only  a  mortality  of  7.8  per  cent.  Why  is  in- 
fection with  typhus  so  common  and  the  mortality  so  high 
among  physicians?  Is  there  an  opportunity  of  direct  infection 
by  some  means  in  which  the  virulence  of  the  infection  (as  in 
pneumonic  plague)  is  uniformly  greater  than  when  it  is  trans- 
mitted through  the  intermediate  host,  in  the  case  of  typhus, 
the  louse;  and  in  bubonic  plague,  the  flea? 

Aetiology 

Bacteriological  investigations  in  regard  to  the  aetiology  of 
typhus  were  carried  out  during  the  Serbian  epidemic  in  con- 
nection with  several  of  the  larger  hospitals. 

In  spite  of  the  very  large  amount  of  experimental  work  that 
has  been  performed  in  relation  to  the  causative  organism  of 
typhus,  there  is  no  general  unanimity  of  opinion  upon  the  na- 
ture of  the  virus.  A  number  of  different  investigators  working 
in  different  epidemics  in  various  parts  of  the  world  have  de- 
scribed species  of  cultivable  bacteria  as  the  cause;   others 

1  Friedberger:  Ztschr.  f.  Hyg.  u.  Infectionskrankh.,  1918,  Ixxxvii,  475. 


50  TYPHUS  FEVER 

believe  the  disease  owes  its  origin  to  a  species  of  protozoa,  and 
still  others  think  that  it  is  due  to  a  filterable  virus. 

Rocha-Lima  ^  and  a  number  of  other  investigators  regard  the 
so-called  Rickettsia  prowazeki  as  the  cause.  Different  bacilli, 
each  regarded  as  specific,  have  been  reported,  particularly  by 
Horiuche  ^  in  1909,  Ricketts  and  Wilder  in  1910,^  Plotz,  1914,^ 
Rabinowitsch,^  Arnheim,'^  Rudisjicinsky,"^  Petruschky,  1915,^ 
and  Zeiss,  1917.^  Specific  cocci  have  been  regarded  as  the  cause, 
particularly  by  Wilson,  1910,^°  Proescher,  1915,^^  Penfold,  1916,^2 
and  Danielopolu,  1917,^^  while  pleomorphic  organisms  (diplo- 
coccoid  and  bacillary  forms)  have  been  described  by  Prejet- 
chensky,^^  Fuerth,  Mueller,  Hort,  and  Ingram,^^  and  Topley^^ 
and  Gaston.^^  In  addition  to  these  claims  Futaki  (1915)^®  has 
described  a  spirochaete,  Goldstein  ^^  a  motile  diplobacillus,  and 
Milman  ^°  a  non-motile  diplobacillus  as  the  cause  of  typhus. 
Wolbach  and  Todd^^  believe  that  the  cause  of  Mexican  typhus 
fever  is  due  to  a  new  parasite  which  they  call  Dermacentroxe- 
nus  typhi:  Weil  and  Felix,^^  Felix,^^  and  Friedberger^^  have  be- 

1  Rocha-Lima:  Arch.  f.  Schiffs-  u.  Tropen-Hyg.,  1916,  xx,  17;  Berl.  klin.  Wchnschr., 
1916,  liii,  567. 

2  Horiuche:  cited  by  Ledingham,  Lancet,  1920,  i,  380. 

3  Ricketts  and  Wilder:  Jour.  Am.  Med.  Assn.,  1910,  liv,  1373. 

4  Plotz:  ibid.,  1914,  Ixii,  1556. 

5  Rabinowitsch:  Berl.  klin.  Wchnschr.,  1914,  li,  1458. 
s  Arnheim:  Deutsch.  med.  Wchnschr.,  1915,  xli,  1060. 

^  Rudisjicinsky:  New  York  Med.  Jour.,  1915,  cii,  1175. 

8  Petruschky:  Centralbl.  f.  BacterioL,  1914-1915,  Orig.,  Abt.  1,  Ixxv,  497. 

9  Zeiss:  Deutsch.  med.  Wchnschr.,  1917,  xliii,  1227. 
1"  Wilson:  cited  by  Ledingham,  Lancet,  1920,  i,  380. 

11  Proescher:  Berl.  klin.  Wchnschr.,  1915,  lii,  805. 

12  Penfold:  Tr.  Soc.  Trop.  Med.  and  Hyg.,  1916,  ix,  105. 

13  Danielopolu:  Presse  med.,  1917,  xxix,  403. 

1*  Prejetchensky:  Typhus  Fever,  cited  by  Cox,  Commonwealth  of  Australia  Quaran- 
tine Service,  1917,  PubUcation  No.  13,  p.  30. 

15  Fuerth,  Mueller,  Hort,  and  Ingram:  cited  by  Cox,  Commonwealth  of  Australia 
Quarantine  Service,  Publication  No.  13,  p.  31. 

18  Topley:  Jour.  Roy.  Army  Med.  Corps,  1915. 

I''  Gaston:  Revue  de  med.,  1915,  xxxiv,  559. 

18  Futaki:  Brit.  Med.  Jour.,  1917,  pp.  265  and  491. 

19  Goldstein:   ibid.,  p.  167. 

20  Milman:  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  2203. 

21  Wolbach  and  Todd:  Ann.  d.  I'lnst.  Pasteur,  1920,  No.  3,  p.  159. 

22  Weil  and  Felix:  Wien.  khn.  Wchnschr.,  1916,  xxix,  33;  ibid.,  1917,  xxx,  393. 

23  Fehx:  Ztschr.  f.  Immunitatsforsch.  u.  exper.  Therap.,  1917,  xxvi,  602. 
"  Friedberger:  Deutsch.  med.  Wchnschr.,  1917,  xHii,  1314. 


THE  SERBIAN  EPIDEMIC  51 

lieved  that  Bacillus  proteus  X  19  possesses  specific  properties 
in  connection  with  the  disease,  and  Werner  and  Leoneanu  ^ 
and  Hilgermann  and  Arnoldi  ^  have  even  made  human  inocula- 
tions for  protection  against  typhus  with  this  organism.  On  the 
other  hand,  Nicolle,  Hort^  and  others  beheve  that  typhus  is  due 
to  a  filterable  virus.  On  account  of  the  attention  that  has  been 
recently  called  to  the  Rickettsia  in  relation  to  the  disease  and 
the  opportunities  for  the  investigation  of  the  aetiology  of  typhus 
which  will  undoubtedly  occur  in  connection  with  the  epidemics 
of  this  disease  in  Central  and  Eastern  Europe,  it  seems  advis- 
able to  present  here  a  detailed  account  of  the  investigations 
which  have  been  already  made  in  relation  to  the  Rickettsia. 

The  Significance  of  Rickettsia  in  Relation  to 
Disease 

In  1916  Rocha-Lima  called  attention  to  the  presence  of  very 
minute  bodies  which  were  found  in  lice  which  had  fed  upon  pa- 
tients suffering  from  typhus  fever.  These  bodies  were  present 
not  only  in  the  contents  of  the  alimentary  canal,  but  especially 
in  the  epithelial  cells  of  the  alimentary  tract  of  these  insects. 
He  regarded  them  as  very  minute  microorganisms.  They  were 
elliptical,  oval,  often  found  in  pairs  and  bipolar  in  appearance. 
The  smallest  forms  measured  from  about  .3  to  A  ix  and  the 
larger  ones,  sometimes  biscuit-shaped,  from  .4  to  .9  m.  They 
were  best  demonstrated  by  staining  in  Giemsa's  solution. 
These  organisms  were  not  at  first  found  in  lice  which  had  not 
fed  upon  cases  of  typhus  fever.  The  lice  were  said  to  become 
parasitized  only  after  ingesting  infected  blood.  Rocha-Lima 
pointed  out  that  while  these  bodies  slightly  resembled  bacteria 
in  their  morphology,  they  were  in  other  respects  more  like  the 
Chlamydozoa-Strongyloplasmata.  He  therefore  proposed  for 
them  the  name  of  Rickettsia  prowazeki  (n.g.  n.sp.)  evidently 
choosing  this  name  in  memory  of  Ricketts  and  Prowazek,  both 
of  whom  succumbed  to  typhus  fever  which  they  contracted 

1  Werner  and  Leoneanu:  Miinchen.  med.  Wchnschr.,  1918,  Ixv,  587. 

2  Hilgermann  and  Arnoldi:  Deutsch.  med.  Wchnschr.,  1917,  xhii,  1582. 

3  Hort:  Brit.  Med.  Jour.,  1917,  p.  265. 


52  TYPHUS  FEVER 

while  pursuing  their  independent  investigations  upon  this  dis- 
ease. Subsequently,  organisms  having  a  similar  appearance 
were  found  by  other  observers  and  also  by  Rocha-Lima  in  lice 
which  had  fed  upon  healthy  individuals  or  on  those  suffering 
with  various  other  diseases.  For  this  second  form  Rocha-Lima 
proposed  the  name  of  Rickettsia  pediculi.  He  believes  that 
Rickettsia  pediculi  differs  from  Rickettsia  prowazeki  in  that  the 
former  is  found  normally  only  in  the  lumen  of  the  alimentary 
canal  of  the  louse,  and  does  not  multiply  in  the  cells  of  the  in- 
sects' alimentary  tract,  or  only  does  so  exceptionally. 

It  is  of  importance  in  considering  the  study  of  the  Rickettsia 
to  recall  that  the  terms  Chlamydozoa  (Prowazek)  ^  Strongylo- 
plasmata  (Lipschuetz)^  were  proposed  to  include  a  group  of  very 
minute  pathogenic  organisms  or  viruses  which  exhibited  cer- 
tain common  properties,  while  exercising  specific  peculiarities 
in  each  case.  These  viruses  are  believed  during  at  least  one 
stage  of  their  development  (that  of  the  "elementary  cor- 
puscles") to  pass  through  bacterial  filters  without  losing  their 
virulence.  Within  the  cells  of  the  host  the  elementary  cor- 
puscles are  believed  to  grow  into  larger  "initial  bodies."  The 
chief  characteristics  of  the  chlamydozoa  ^  were  said  to  be 
firstly,  their  minute  size,  smaller  than  any  bacteria  hitherto 
known,  enabling  them  to  pass  the  ordinary  bacterial  filters 
during  one  stage  of  their  development;  secondly,  that  they 
develop  within  cells,  in  the  cytoplasm  or  nucleus,  and  produce 
characteristic  reaction  products  and  enclosures  of  the  cell; 
thirdly,  that  they  pass  through  a  series  of  developmental  stages 
and  are  specially  characterized  by  their  mode  of  division, 
which  is  not  a  simple  process  of  splitting  as  in  bacteria,  but  is 
effected  with  formation  of  a  dumb-bell  shaped  figure  as  in  the 
division  of  a  centriole.  Two  dots  are  seen  connected  by  a  fine 
line  like  a  centrodesmus,  which  becomes  drawn  out  until  it 
snaps  across  the  middle,  and  its  two  halves  are  then  retracted 
into  the  body.  In  appearance  the  chlamydozoa  seem  to  consist 
primarily  of  merely  a  grain  of  chromatin  without  cytoplasm 

1  Arch.  f.  Protistenkunde,  1907,  x,  336. 

2  Handbuch  der  Pathogenen  Protozoen,  Leipzig,  1911,  Prowazek  and  others. 
^  Minchen:  Introduction  to  the  Study  of  the  Protozoa,  London,  1917,  p.  472. 


THE  SERBIAN  EPIDEMIC  53 

and  without  a  membrane  of  any  kind.  Hence  they  appear  to 
represent  the  simplest  form  of  Hving  body.  The  chlamydozoa 
have  not  yet  been  successfully  cultivated,  but  infections  can  be 
produced  with  pure  colloid-filtrates  free  from  bacteria,  but 
containing  the  minute  bodies  themselves.  They  are  char- 
acteristically parasites  of  epiblastic  cells  and  tissues.  The 
viruses  of  trachoma,  vaccinia,  scarlet  fever,  hydrophobia,  mol- 
luscum  contagiosum,  and  more  recently  of  typhus  fever,  have 
been  referred  to  the  chlamydozoa. 

Previous  to  Rocha-Lima's  observations,  several  investiga- 
tors had  published  articles  describing  microorganisms  observed 
in  lice  which  had  fed  upon  typhus  fever  patients,  and  Ricketts 
described  a  somewhat  similar  organism  in  connection  with 
Rocky  Mountain  fever.  It,  therefore,  is  advisable  to  consider 
these  investigations  in  chronological  order  in  connection  with 
the  discussion  of  this  subject. 

In  1909  Ricketts  ^  reported  upon  the  occurrence  of  diplo- 
coccoid  bodies  and  short  bacillary  forms  in  the  blood  of  guinea 
pigs  and  monkeys  which  had  been  experimentally  infected  with 
blood  from  cases  of  Rocky  Mountain  spotted  fever.  These 
organisms  were  also  seen,  but  not  so  frequently,  in  the  blood  of 
man.  They  were  also  encountered  in  the  female  tick  (Derma- 
centor  occidentalis)  and  in  the  eggs  of  these  ticks  which  had  fed 
upon  infected  guinea  pigs.  Ricketts  describes  his  method  of 
examination  and  the  organism  itself,  as  seen  in  the  eggs,  as  fol- 
lows: "A  number  of  eggs  from  the  first  day's  laying  were 
crushed  on  cover  glasses,  fixed  in  absolute  alcohol  and  stained 
with  Giemsa's  solution.  Each  egg  was  found  to  be  laden  with 
astonishing  numbers  of  an  organism  which  appears  typical  as  a 
bipolar  staining  bacillus  of  minute  size,  approximately  that  of 
the  influenza  bacillus.  Although  definite  measurements  have 
not  yet  been  made,  it  is  very  common  to  find  two  organisms 
end  to  end  with  their  poles  stained  deeply.  In  some  instances 
thousands  of  these  organisms  were  found,  many  staining 
faintly."  Morphologically,  the  organism  appeared  to  him  to  be 

,  1  Ricketts:  Jour.  Am.  Med.  Assn.,  1909,  lii,  379,  and  Med.  Rec,  N.  Y.,  1909,  Ixxvi, 
842. 


54  TYPHUS  FEVER 

a  bacillus,  and  he  points  out  that  its  resemblance  to  the  bacillus 
of  haemorrhagic  septicaemia  is  striking,  though  he  was  not  able 
to  cultivate  it.  He  suggests  that  the  organism  in  question  be 
called  the  bacillus  of  Rocky  Mountain  fever. 

Ricketts  and  Wilder  ^  in  1910  described  the  organism  of 
typhus  fever,  which  disease  they  studied  in  Mexico.  In  prep- 
arations of  the  blood  of  patients  taken  from  the  seventh  to  the 
twelfth  day  of  the  disease,  stained  with  Giemsa's  solution,  they 
invariably  found  a  short  bacillus  which  had  roughly  the  mor- 
phology of  those  organisms  belonging  to  the  haemorrhagic 
septicaemia  group.  Usually,  this  bacillus  appeared  to  stain 
solidly,  but  on  minute  examination  an  unstained  or  faintly 
stained  bar  was  seen  to  extend  across  the  middle.  The  exact 
measurements  were  not  made,  but  when  compared  with  the 
size  of  the  erythrocyte,  their  length  was  estimated  at  hardly 
more  than  two  micromillimeters  and  their  diameter  at  about 
one-third  of  this  figure.  They  also  described  involution  forms 
of  the  organism.  No  active  motility  was  observed  in  fresh 
preparations.  These  bipolar  organisms  were  found  in  the  de- 
jecta and  in  various  organs  of  lice  which  had  been  infected  by 
feeding  on  typhus  patients.  While  they  were  also  found  oc- 
casionally in  the  faeces  and  intestinal  contents  of  normal  lice, 
they  were  present  almost  constantly  and  often  in  large  numbers 
in  lice  from  infected  individuals. 

Gavin  and  Girard  ^  found  in  the  blood  of  patients  in  Mexico 
bacilliform  bodies  2  ^u  in  length  by  1.2  /^  in  width,  which  when 
treated  with  Giemsa's  solution  exhibited  at  the  extremities 
two  small,  deeply-stained  masses  united  by  a  slightly  stained 
portion.  They  regarded  the  significance  of  these  bodies  as 
obscure,  and  did  not  consider  their  aetiological  significance 
demonstrated. 

In  1913  Prowazek,^  in  the  examination  of  the  blood  of  51 
cases  of  typhus  observed  in  Belgrade,  found  that  the  poly- 
morphonuclear leucocytes  showed  striking  changes.    The  nu- 

1  Ricketts  and  Wilder:  Jour.  Am.  Med.  Assn.,  1910,  liv,  1373. 

2  Gavin  and  Girard:  Publ.  del  Inst.  bact.  nacional,  Mexico,  20  mai  et  20  juin  1910; 
Bull,  de  rinst.  Pasteur,  1910,  viii,  841. 

'  Hegler  and  Prowazek:  Berl.  klin.  Wchnschr.,  1913,  1,  2035. 


THE  SERBIAN  EPIDEMIC  55 

cleus  showed  signs  of  fragmentation  and  the  whole  leucocytes 
became  filled  with  particles  of  chromatin.  These  cells  stained 
intensely  red  with  Giemsa's  solution  and  were  found  to  contain 
numerous  rod-shaped  and  round  bodies;  diplococcus  forms  and 
frequently  irregular  granules  were  also  observed.  At  the  begin- 
ning of  the  infection  many  of  the  leucocytes  were  free  from 
these  bodies,  but  later  more  of  them  contained  them.  Pro- 
wazek,  in  discussing  the  nature  of  these  bodies,  inclined  to  the 
belief  that  they  were  related  to  the  strongyloplasmata  described 
by  Lipschuetz,  which  belonged  to  the  chlamydozoa.  These 
bodies  tended  to  disappear  during  the  convalescence  of  the 
patient.  In  addition,  he  observed  in  the  blood  of  a  number  of 
cases  the  curious  double  bodies  similar  to  those  first  described 
by  Ricketts  and  Wilder,  but  he  remarks  that  the  significance  of 
these  forms  is  still  very  obscure.  In  the  examination  of  sections 
of  organs  of  typhus  cases,  trachoma-like  bodies  were  observed 
in  the  endothelial  cells  of  the  heart,  lung,  fiver,  and  kidney. 
Infected  lice  were  carefully  examined,  and  in  one  case  small 
coccoid  bodies  and  also  diplococcus  forms  were  observed. 

Sergent,  Foley,  and  Vialatte  ^  in  1914  working  in  Algeria 
found  in  lice  living  only  on  the  sick  —  never  in  those  living  on 
healthy  people  or  on  people  suffering  from  recurrent  fever  — 
an  organism  of  which  the  following  description  is  given:  the 
microbe  has  the  appearance  of  a  coccobacillus.  The  staining  of 
the  poles  though  never  very  intense  is  more  pronounced  than 
that  of  the  central  portion,  which  is  occasionally  quite  trans- 
parent. The  length  varies  from  1-3  m  and  the  thickness  be- 
tween .5  and  .8  m-  Some  of  the  small  forms  are  shaped  like 
seeds  with  a  diameter  of  .7  /i.  These  organisms  are  frequently 
seen  in  pairs.  When  the  germs  are  abundant  they  become 
elongated,  forming  chains  with  hardly  distinguishable  links. 
They  were  found  in  greater  number  in  the  bloody  fiuid  of  the 
digestive  tract  of  the  lice  than  in  smears  of  their  organs  after 
crushing.  The  organisms  were  few  during  the  first  days  of  ill- 
ness and  could  be  observed  only  in  a  small  proportion  of  the 
lice  examined;  but  their  number  increased  gradually  and  more 

'  Sergent,  Foley,  and  Vialatte:  Compt.  rend.  Soc.  de  Biol.,  1914,  Ixxvii,  101. 


56  TYPHUS  FEVER 

lice  became  infected.  A  number  of  such  lice  were  fed  on 
healthy  individuals  and  the  proportion  of  microbes  seen  be- 
came much  larger.  From  the  twentieth  to  the  twenty-fifth  day 
most  of  the  lice  showed  signs  of  infection.  The  above-mentioned 
authors  did  not  succeed  in  cultivating  this  microorganism 
on  artificial  media.  They  thought  the  microbe  observed  by 
them  might  be  identical  with  that  described  by  Ricketts  and 
Wilder  in  the  louse.  They  terminate  their  remarks  with  the 
conservative  statement  that  if  the  coccobacillus  described 
above  does  not  constitute  the  virus  of  exanthematic  typhus,  it 
may,  however,  be  supposed  that,  as  is  the  case  in  a  number 
of  the  pasteurella,  it  is  a  'Hemoin"  microbe  which  accompanies 
the  true  invisible  infectious  agent. 

Nicolle,  Blanc,  and  Conseil  ^  in  1914  found  in  Tunis  the 
coccobacillus  described  by  Sergent  and  his  collaborators  in  five 
per  cent  of  the  lice  collected  in  districts  which  had  been  free 
from  typhus  for  two  years.  In  consequence  they  considered 
that  this  germ  could  not  be  the  agent  which  produces  typhus. 
They  found  that  lice  fed  on  typhus  cases  did  not  become  infec- 
tive before  the  eighth  day,  but  are  constantly  infectious  on  the 
ninth  and  tenth  days.  Two  attempts  to  filter  the  virus  of 
typhus  obtained  by  grinding  up  140  and  155  infected  lice  both 
gave  uncertain  results  and  therefore  they  believed  that  the 
filterability  of  the  causative  agent  of  this  disease  cannot  be 
regarded  as  certain.  They  could  not  detect  any  organism  in 
the  blood  and  organs  of  guinea  pigs  infected  with  typhus. 

Proescher  in  1915  ^  examined  blood  smears  from  nine  typhus 
cases  after  staining  with  one  per  cent  solution  of  methylene- 
azur-carbonate.  Endothelial  cells  from  the  blood-vessels  were 
found  containing  very  small  diplococci  and  diplobacilH,  meas- 
uring from  .2  to  .3  M-  They  were  found  either  singly  in  short 
chains  or  in  groups.  Very  few  were  seen  in  the  plasma  and  in 
the  polynuclear  leucocytes.  These  bodies  were  not  found  in 
normal  blood  or  in  blood  from  cases  of  measles,  mumps,  scarlet 
fever,  cholera,  and  relapsing  fever.    The  author  suggests  that 

'  Nicolle,  Blanc,  and  Conseil:  Compt.  rend.  Acad.  d.  sc,  1914,  clix,  661,  and  Arch. 
de  I'Inst.  Pasteur  de  Tunis,  1914,  ix,  84.''^' 

=>  Proescher:  Berl.  khn.  Wchnschr.,  191S>;|ii,  805. 


THE  SERBIAN  EPIDEMIC  57 

these  minute  bodies  may  be  the  cause  of  typhus,  but  he 
points  out  as  they  have  not  yet  been  cultivated  this  fact  has 
not  been  demonstrated.  He  beheves  the  nature  of  the  bodies 
described  by  Prowazek  is  still  uncertain  and  states  they  are 
smaller  than  the  diplococci  and  diplobacilli  he  has  found. 
Whether  they  are  quite  different  structures  or  cocci  under- 
going phagocytosis  degeneration  products,  or  granules,  is  still 
doubtful. 

Dorendorf  ^  in  the  examination  of  the  blood  of  typhus  fever 
cases  in  Serbia  discovered  in  all  cases  examined  during  the 
febrile  stage  of  the  disease  the  organisms  previously  described 
by  Prowazek.  These  bodies  were  found  in  the  plasma,  in  the 
polymorphonuclear  and  mononuclear  leucocytes,  either  singly 
or  in  pairs.  Nuclear  variations  were  a  marked  feature  in  the 
blood  picture  of  the  severe  cases,  and  these  changes  were  also 
seen  in  the  mild  cases  at  the  height  of  the  fever. 

Stempell  ^  in  1916,  in  dissecting  lice  collected  from  sick 
people,  found  among  the  enigmatic  parasites  brownish  bodies 
in  the  intestinal  epithelium  of  the  louse  which  he  named 
Strickeria  jungensi  n.g.  n.sp.  He  considered  these  organisms  as 
the  cause  of  typhus.  Coccoid  forms  encountered  were  attrib- 
uted to  the  same  parasite. 

Lipschuetz  ^  observed  in  the  polymorphonuclear  leucocytes 
in  blood  from  typhus  cases  bodies  like  those  that  Prowazek  had 
described.  Of  23  cases  examined,  18  were  positive  and  5  nega- 
tive. These  bodies  were  not  found  in  control  preparations  from 
typhoid  fever  and  variola  cases,  or  in  normal  blood  prepara- 
tions. He  believes  that  while  their  nature  is  obscure  they  may 
be  of  service  in  the  diagnosis  of  the  disease.  , 

Csernel  ^  describes  the  bodies  found  in  typhus  blood  which 
seem  to  be  the  causal  agent  of  the  disease.  He  gives  illustra- 
tions of  these  bodies.  They  show  two  distinct  phases.  One  a 
bipolar  bacillus  which  he  regards  as  the  virulent  form,  and  a 
long  bacillus  which  he  believes  to  be  a  saprophytic  one.  In 
three  cases  he  detected  flagella,  and  was  unable  to  explain  their 
presence. 

1  Dorendorf:  Deutsch.  med.  Wchnschr.,  1916,  xlii,  345.         ?  Stempell:  ibid.,  439. 
'  Lipschuetz:  Wien.  klin.  Wchnschr.,  1916,  xxix,  549.  *  Csernel:  ibid.,  1643. 


58  TYPHUS  FEVER 

Zollenkopf  ^  in  describing  a  new  disease  resembling  inter- 
mittent fever  (probably  Volhynia  fever)  found  changes  in  the 
red  cells,  consisting  of  blue  dots  and  rods,  as  many  as  eight  or 
twelve  in  a  corpuscule.  These  were  not  found  in  preparations 
taken  after  the  fever,  and  the  author  thinks  they  may  be  only 
basophilic  granules  in  the  erythrocytes. 

Rocha-Lima  and  Prowazek  ^  found  during  investigations 
carried  out  at  the  Prison  Camp,  Kottbus,  that  95  per  cent  of 
the  lice  taken  from  sick  people  were  infected  by  a  parasitic 
microorganism.  The  organisms  were  found  not  only  in  the  con- 
tents of  the  alimentary  canal,  but  especially  in  the  epithelial 
cells  of  the  alimentary  tract.  They  were  not  found  in  lice 
living  on  healthy  subjects,  but  on  the  other  hand  non-infected 
lice  placed  on  sick  patients  became  infected  with  them.  Refer- 
ence has  already  been  made  in  the  beginning  of  this  article  to 
the  fact  that  Rocha-Lima  believed  that  while  these  bodies  were 
somewhat  bacterial-like  in  appearance,  they  resembled  more 
closely  the  chlamydozoa,  and  he  therefore  proposed  the  name 
of  Rickettsia  prowazeki  for  them  —  n.g.  n.sp.  He  believed  that 
this  organism  could  penetrate  the  cells  of  the  alimentary  canal 
of  the  louse  and  multiply  actively  there.  He  observed  that  this 
parasite  has  been  found  in  man  only  in  the  leucocytes. 

Rocha-Lim'a  ^  in  another  publication  points  out  that  in 
December,  1914,  in  streak  preparations  made  from  lice  which 
had  fed  on  typhus  cases,  he  found  large  numbers  of  bacillus- 
Hke  bodies  which  stained  red  with  Giemsa's  solution.  These 
organisms  did  not  stain  well  with  the  usual  bacteriological 
stains.  When  Prowazek  arrived,  he  recognized  that  these 
bodies  were  the  same  as  those  already  seen  by  him  in  1913  in 
a  preparation  from  an  infected  louse.  By  the  examination  of 
a  number  of  sections  of  lice  from  typhus  cases,  and  of  normal 
lice,  it  was  found  that  the  bacillus-like  bodies  were  present  in 
large  numbers  in  the  cells  of  the  alimentary  canal  and  in  the 
salivary  glands  of  infected  lice,  but  were  not  present  in  normal 

1  Zollenkopf:  Deutsch.  med.  Wchnschr.,  1916,  xlii,  1034. 

*  Rocha-Lima  and  Prowazek:  Berl.  klin.  Wchnschr.,  1916,  liii,  567. 

3  Rocha-Lima:  Arch.  f.  Schiffs-  u.  Tropen-Hyg.,  1916,  xx,  17. 


THE  SERBIAN  EPIDEMIC  59 

lice.  Of  18  lice  taken  from  a  sick  patient,  17  were  infected  by 
this  microorganism.  The  organism  described  by  him  appeared 
as  a  coccobacillus  which  could  be  easily  stained  by  Giemsa's 
solution.  In  the  beginning,  the  parasites  were  slightly  elliptical 
in  shape.  Later,  during  the  course  of  the  division  they  became 
elongated.  The  two  poles  were  deeply  stained,  and  joined  by  a 
faintly  tinted  envelope.  The  organisms  did  not  stain  well  with 
the  usual  reagents,  and  did  not  retain  Gram's  stain.  In  order  to 
measure  the  microorganisms,  he  submitted  them  to  a  magnifi- 
cation of  3000  diameters.  The  smallest  forms  measured  from 
.3  to  .4  iJL,  while  the  biscuit-shaped  forms  measured  from  .3  to 
.9  M-  Only  a  similar  picture  regarding  the  occurrence  of  these 
bodies  in  infected  Hce  had  he  observed  up  to  the  present  time  in 
normal  lice,  and  not  an  identical  one. 

The  Rickettsia  made  their  appearance  in  the  cells  of  the  in- 
testine of  lice  on  the  fourth  or  fifth  day  after  they  had  been 
placed  on  the  patient,  but  they  did  not  achieve  their  complete 
development  before  the  eighth  or  ninth  day.  They  developed 
rapidly  at  32°  but  not  below  23°. 

Rocha-Lima's  experiments  with  respect  to  the  filterability  of 
the  tj^hus  virus  did  not  give  positive  results,  the  Rickettsia 
appearing  to  remain  in  the  Berkefeld  V  filter  employed.  At- 
tempts to  cultivate  the  organism  of  tjrphus  on  various  agar 
media  with  the  addition  of  ascitic  fluid,  blood  or  extracts  of  the 
organs  of  rabbits  or  of  lice  were  also  unsuccessful.  He  refers  to 
the  fact  that  of  all  the  bacteria  described  as  the  cause  of  typhus, 
the  organism  of  Plotz  might  seem  to  be  the  most  plausible. 
However,  he  remarks  that  the  almost  entirely  negative  results 
with  animal  experiments  in  an  infection  which  is  so  easily  trans- 
mitted to  animals  as  typhus  confirms  our  scepticism  regarding 
it.  He  also  refers  to  Petruschky 's  ^  work,  and  points  out  that  the 
organism  he  has  described  has  only  been  demonstrated  in  the 
sputum,  in  which  the  virus  has  not  been  proven  to  be  present. 
He  believes  that  the  bacillus  described  by  Arnheim  ^  evidently 
belongs  to  the  pseudodiphtheria  group  of  organisms.    He  con- 

1  Petruschky:  Centralbl.  f.  Backteriol.,  Orig.,  Abt.  1,  1914-15,  Ixxv,  497. 

2  Arnheim:  Deutsch.  med.  Wchnschr.,  1915,  xli,  1060. 


60  TYPHUS  FEVER 

siders  the  bodies  that  he  has  described  are  really  the  aetiologic 
agents,  because  he  has  transmitted  the  disease  to  guinea  pigs 
by  the  injection  of  lice  containing  these  parasites,  and  the  dis- 
ease produced  was  identical  to  that  produced  in  animals  in- 
oculated with  the  blood  of  typhus  patients. 

In  a  third  article  Rocha-Lima  ^  alludes  to  the  fact  that 
Ricketts  and  Wilder  found  polar  staining  organisms  occasion- 
ally in  the  faeces  and  intestinal  contents  of  normal  lice,  whereas 
they  found  them  almost  continuously  and  often  in  large  num- 
bers in  similar  material  from  infected  lice.  In  proposing  the 
names  of  Rickettsia  prowazeki  for  this  organism  as  the  cause  of 
typhus,  he  points  out  that  the  Gram-positive  diplobacillus  of 
Rabinowitsch,  the  paratyphus-like  bacillus  of  Horiuche,  the 
aerobic,  bipolar  bacillus  of  Prejetchensky,  as  well  as  the  Bacil- 
lus violentus  parvus  of  Klodnitsky  were  even  more  strongly 
agglutinated  with  typhus  fever  serum  than  the  strict  anaerobic 
organism  of  Plotz.  He  showed  that  a  louse  which  was  fed  upon 
a  typhus  patient  on  the  fourth  day  of  the  disease  showed  the 
presence  of  Rickettsia  infection  four  days  afterwards.  This 
louse  was  proved  infective  by  animal  experiment  as  well  as  by 
microscopical  examination,  the  animal  inoculated  with  it 
having  contracted  typhus  infection. 

In  still  another  publication  Rocha-Lima  ^  admits  that  it  has 
not  been  conclusively  proved  that  typhus  fever  is  caused  by 
Rickettsia  prowazeki.  He,  however,  alludes  to  the  fact  that 
organisms  which  are  not  dissimilar  to  the  Rickettsia  and  which 
may  be  identical  have  been  described  in  connection  with  typhus 
fever  by  Ricketts  and  Wilder,  by  Gavin  and  Girard  and 
McCampbell  in  the  blood  serum,  by  Prowazek  in  the  leuco- 
cytes, and  by  Rocha-Lima  in  the  blood  and  organs  and  in  sec- 
tions. He  thinks,  however,  that  the  final  proof  is  still  wanting 
that  these  bodies  are  identical  and  are  the  cause  of  typhus,  and 
the  dimensions  given  by  Rocha-Lima  for  these  organisms  are 
considerably  below  those  given  by  Ricketts  and  by  Sergent  and 
his  collaborators.  He  believes  that  the  bodies  described  by 
Hanser  in  skin  sections  from  cases  of  typhus  fever  are  entirely 

1  Rocha-Lima:  Mtinchen.  med.  Wchnschr.,  1916,  Ixiii,  1381.       ^  i^id.,  1917,  Mv,  33. 


THE  SERBIAN  EPIDEMIC  61 

different  from  the  Rickettsia,  and  that  the  organism  described 
by  Toepfer  in  typhus  fever  cases  is  not  unlike  the  bacillus  de- 
scribed by  Rabinowitsch  in  1909. 

Munk  and  Rocha-Lima  ^  further  describe  the  difficulties  in 
distinguishing  Rickettsia  from  other  bodies  such  as  elements  of 
tissue,  granulations  or  coagula,  and  point  out  that  they  can 
only  be  identified  as  microorganisms  when  in  large  numbers 
and  when  distinctly  stained.  They  believe  that  it  is  really  im- 
possible even  for  the  experienced  eye  to  identify  Rickettsia 
prowazeki  by  its  morphology  alone,  as  has  been  demonstrated  by 
finding  similar  microorganisms  in  lice  not  infectious.  They  em- 
phasize that  the  difference  between  Rickettsia  prowazeki  and  the 
Rickettsia  pediculi  is  that  the  former  develops  in  the  epithelial 
cells  of  the  stomach  and  small  intestine  of  the  lice,  while  the 
latter  lies  in  the  lumen  of  the  digestive  tube.  They  point  out 
that  the  Rickettsia  found  in  lice  taken  from  cases  of  Volhynia 
fever  and  from  other  patients,  or  even  from  healthy  people, 
increase  normally  in  the  lumen  of  the  alimentary  canal  and 
penetrate  only  exceptionally  into  the  cells.  They  remark  that 
Nicolle,  Blanc,  and  Conseil  found  the  same  organism  in  a  cer- 
tain percentage  of  normal  lice,  and  that  Toepfer  and  Jung- 
mann  found  the  Rickettsia  in  lice  from  Volhynia  fever  cases, 
and  that  these  Rickettsia  also  were  intracellular.  Rocha-Lima 
and  Munk  believe  that  the  intracellular  Rickettsia  are  excep- 
tional, except  in  connection  with  typhus,  and  are  different  from 
those  observed  in  the  lice  fed  on  .Volhynia  fever  cases. 

In  relation  to  the  microscopical  study  of  the  blood  in  Vol- 
hynia fever,  they  remark  that  Jungmann,  His,  Toepfer,  and 
Korbsch  thought  this  disease  was  due  to  a  diplobacillus,  while 
Toepfer,  Korbsch,  and  Riemer  thought  the  cause  was  a  spiro- 
chaete.  Rocha-Lima  and  Munk  found  diplobacillus-like  forms 
in  the  blood  of  Volhynia  fever  cases,  but  they  also  found  the 
same  forms  in  the  blood  taken  from  patients  with  other  diseases 
or  even  from  healthy  people.  For  this  reason,  Toepfer  and  the 
authors  came  to  the  conclusion  that  the  bodies  described  by 
the  investigators  named  above,  and  by  Jungmann  and  Ku- 

1  Munk  and  Rocha-Lima:  Miinchen  med.  Wchnschr.,  1917,  xliv,  1422. 


62  TYPHUS  FEVER 

czynski,  were  probably  not  the  cause  of  Volhynia  fever,  and 
that  this  link  in  the  chain  of  proof  concerning  the  Rickettsia  as 
the  cause  of  typhus  also  is  still  lacking,  particularly  since 
morphologically  the  bodies  found  in  normal  blood  cannot  be 
differentiated  from  those  found  in  typhus  blood.  Rocha-Lima 
and  Munk  were  able  to  transmit  Volhynia  fever  to  guinea  pigs 
by  the  injection  of  the  blood,  but  not  to  mice  as  Jungmann  and 
Kuczynski  had  done.  From  this,  it  would  appear  that  they 
were  not  working  with  trench  fever  since  this  disease  has  not 
been  communicated  to  guinea  pigs.  They  were  able  to  produce 
the  disease  in  two  guinea  pigs  inoculated  with  the  urine  from 
Volhynia  fever  cases,  but  a  bacteriological  examination  of  this 
urine  did  not  reveal  the  cause  of  the  disease.  The  question  of 
the  filterability  of  the  virus  of  Volhynia  fever  they  still  consider 
doubtful. 

Munk  and  Rocha-Lima  performed  further  experiments  in 
cultivation  of  the  Rickettsia,  but  these  were  not  successful. 

In  70  experiments  on  patients  of  whom  Munk  had  made  the 
diagnosis  of  Volhynia  fever,  51  gave  a  positive  result  with  re- 
gard to  the  infection  of  one  louse  at  least  with  Rickettsia  pedi- 
culi,  11  remained  negative,  and  6  were  doubtful.  Among  the 
negative  instances  were  some  typical  cases  which,  although 
repeated,  gave  the  same  results.  In  33  control  tests  of  pa- 
tients whom  Munk  considered  did  not  have  this  fever,  26  re- 
mained negative,  and  6  infected  in  the  same  way  as  the  lice 
from  the  Volhynia  fever  cases,  while  1  test  remained  doubt- 
ful. These  control  tests  were  made  on  people  in  the  hospital  for 
other  diseases,  such  as  malaria,  scarlet  fever,  measles,  diph- 
theria, trichinosis,  typhoid  fever,  tuberculosis,  rheumatism, 
stomach  and  bladder  diseases,  and  inguinal  hernia.  The  6 
cases  upon  which  the  lice  were  fed,  which  later  were  positive  for 
Rickettsia  were  —  3  with  malaria,  1  with  bladder  disease,  1 
with  bronchitis,  and  1  with  inguinal  hernia.  One  who  had 
never  suffered  from  any  disease  gave  rise  to  particularly 
strongly  infected  lice.  Among  infected  lice  taken  from  14 
people,  examined  at  Hamburg,  the  lice  from  2  of  these  peo- 
ple were  found  severely  infected  by  a  microorganism  which 


THE  SERBIAN  EPIDEMIC  63 

could  not  be  differentiated  from  Rickettsia  pediculi  either  in 
.smears  or  in  sections.  One  case  was  undiagnosed.  The  second 
was  that  of  a  workman  who  had  never  been  ill,  who  did  not 
leave  Hamburg,  and  had  never  been  in  connection  with  soldiers 
at  the  front.  These  results  confirm  those  formerly  published. 
In  all  these  cases  the  intracellular  characteristic  development 
of  Rickettsia  prowazeki  was  absent.  The  author  states  that  one 
might  think  Rickettsia  pediculi  the  cause  of  Volhynia  fever,  but 
the  fallacy  of  such  an  idea  is  shown  by  the  fact  that  these  or- 
ganisms have  been  found  in  a  number  of  control  tests  in  lice 
from  healthy  people  in  a  country  free  from  Volhynia  fever. 
The  author  admits  that  it  is  not  impossible  that  the  Rickettsia 
pediculi  may  be  the  cause  of  Volhynia  fever,  but  it  is  impossible 
to  differentiate  this  form  for  the  present  from  that  found  in  lice 
fed  on  healthy  human  beings.  Rocha-Lima,  however,  does  not 
believe  that  Rickettsia  pediculi  is  the  cause  of  Volhynia  fever. 
He  states,  moreover,  that  it  is  only  a  supposition  that  this  dis- 
ease is  carried  by  lice.  Both  Korbsch  and  himself  attempted 
the  propagation  of  this  disease  with  lice,  but  their  experiments 
were  not  successful,  although  the  lice  were  strongly  infected. 

Noeller  ^  believes  in  the  pathogenic  properties  of  Rickettsia 
prowazeki,  though  he  gives  no  important  evidence  of  the  proof 
of  this  idea.  He  demonstrated  in  a  series  of  experiments  that 
lice  from  pigs  transferred  from  infected  guinea  pigs  to  pig  blood 
lived  long  enough  for  the  Rickettsia  to  develop  in  them,  and 
that  the  pig  blood  was  not  detrimental  to  the  development  of 
the  Rickettsia.  He  did  not  think  that  the  infection  of  the  lice 
was  hereditary  with  this  organism. 

Toepfer  and  Schuessler  ^  carried  out  investigations  upon 
about  2000  lice  taken  from  patients.  In  400  lice  which  had  fed 
on  35  patients,  bacteria-like  organisms  were  found  in  the  in- 
fected hce.  These  organisms,  whose  form  and  appearance  they 
say  are  characteristic,  were  constantly  present  in  the  intestinal 
canal  of  the  lice  removed  from  typhus  fever  patients.  They 
were  also  often  present  in  the  cells  of  the  alimentary  tract. 

1  Noeller:  Berl.  klin.  Wchnschr.,  1916,  liii,  778. 

2  Toepfer  and  Schuessler:  Deutsch.  med.  Wchnschr.,  1916,  xlii,  1157. 


64  TYPHUS  FEVER 

Control  lice  fed  on  other  individuals  than  those  suffering  with 
typhus  fever  remained  free  from  these  organisms.  From  mi- 
croscopical examination,  the  organisms  seemed  to  be  in  pure 
culture  in  the  infected  lice.  This  organism  was  found  only  in 
lice  which  had  been  fed  for  some  days  on  the  blood  of  patients 
during  the  febrile  period.  Lice  fed  during  the  postfebrile  period 
did  not  apparently  become  infective.  The  eggs  and  offspring  of 
the  infected  lice  were  not  found  capable  of  producing  infection. 
The  parasites  continued  to  develop  in  the  intestine  of  the  lice 
and  apparently  remained  infective  indefinitely.  They  were 
not  able  to  cultivate  the  organism.  The  injection  of  the  con- 
tents of  the  alimentary  tract  of  an  infected  louse  into  a  healthy 
guinea  pig  produced  a  febrile  condition  similar  to  that  pro- 
duced by  the  injection  of  the  blood  of  a  typhus  fever  patient. 

In  connection  with  Volhynia  fever  Toepfer  ^  called  attention 
to  the  presence  of  characteristic  bodies  in  the  blood  in  Volhynia 
fever.  In  three  cases  of  this  disease  he  observed  spirochaetes.' 
In  one  instance,  in  a  fresh  specimen,  the  organism  was  motile. 
In  lice  taken  from  typhus  fever  patients  he  found  bodies 
similar  to  those  described  by  Rocha-Lima.  He  is  unwilling  to 
commit  himself  whether  a  connection  exists  between  these 
bodies  and  the  spirochaetes. 

In  another  paper  relating  to  Volhynia  fever,,  Toepfer  ^  ex- 
presses the  opinion  that  the  organisms  described  by  His  and 
Werner  as  the  cause  of  this  fever  were  accidental  artefacts.  He 
found  in  the  blood  smaU  parasitic-like  bodies,  but  did  not  con- 
sider that  these  were  diagnostic.  He,  however,  convinced  him- 
self that  the  virus  was  circulating  in  the  blood  in  this  disease 
as  he  performed  experiments  by  injecting  five  cubic  centimeters 
of  blood  intraperitoneally  into  guinea  pigs  and  obtained  similar 
temperature  curves  to  those  which  were  injected  with  blood 
from  tjrphus  patients.  He  found  that  lice  taken  from  typical 
cases  of  Volhynia  fever  contained  in  their  alimentary  tract 
bodies  similar  to  the  typhus  fever  organism.  These  bodies  were 
fouriLd  both  free  and  inside  the  cells  of  the  louse,  and  appeared 

1  Toepfer:  Berl.klin.Wch'nschr.,  1916,  liii,  323. 
;  2  Ibid.:  Muiichen  med.  Wchnschr.,  1916,  Ixiii,  1495. 


THE  SERBIAN  EPIDEMIC  65 

as  small  short  rods.  Polar  staining  rods  and  diplobacilli  forms 
were  present.  He  believes  these  organisms  to  be  bacilli  and  not 
protozoa,  and  considers  that  they  are  the  cause  of  the  disease. 

Toepfer  ^  in  a  more  recent  work  examined  smears  and  sec- 
tions of  500  lice.  He  believes  he  has  confirmed  his  former  ob- 
servations regarding  the  presence  of  an  organism  in  infected 
lice.  He  criticizes  the  name  of  Rickettsia  prowazeki  as  giving  a 
wrong  impression  of  the  nature  of  these  organisms.^ 

He  found  the  same  parasite  in  lice  {Pediculus  capitis)  taken 
from  the  heads  of  patients,  and  he  was  also  able  to  artificially 
infect  normal  lice  of  this  species  by  placing  them  upon  the  sick. 
Smears  made  from  lice  which  had  previously  fed  on  the  blood  of 
patients  infected  with  typhus  fever  were  found  to  contain 
nearly  pure  cultures  of  the  organisms. 

In  another  paper  on  the  aetiology  of  typhus,  Toepfer  ^  de- 
scribes the  organism  found  in  tissues  of  typhus  patients  and  in 
infected  lice  as  intracellular  diplobacilli. 

Hanser  ^  reports  that  he  has  confirmed  Toepfer's  discovery 
of  bacteria-like  forms  in  the  intestinal  cells  of  lice  fed  on  typhus 
fever  patients. 

Toepfer^  in  another  article  upon  war  nephritis  describes 
similar  organisms  to  those  which  he  had  observed  in  lice  fed 
upon  cases  of  typhus  fever  or  of  Volhynia  fever.  He  regards 
this  form  of  nephritis  as  a  specific  disease,  probably  transmit- 
ted by  lice.  He  also  considers  it  plausible  that  the  virus  circu- 
lates in  the  blood.  Guinea  pigs  inoculated  with  blood  from  the 
nephritic  cases  grew  lean  and  had  bloody  urine,  but  no  rise  in 
temperature.  In  the  lice  from  the  nephritic  cases,  especially 
those  which  had  fed  during  the  early  stages  of  the  disease, 
definite  bacteria  were  found  almost  without  exception.  He  also 
infected  lice  by  feeding  them  on  the  nephritic  cases,  and  in 
order  to  control  these  results  he  put  lice  of  the  same  breed  upon 
healthy  people  and  these  remained  uninfected.     These  or- 

^  Toepfer:  Deutsch.  med.  Wchnschr.,  1916,  xlii,  1251. 

^  Rocha-Lima  (ibid.,  1353)  in  a  subsequent  paper  controverts  the  statement  of 
Toepfer  regarding  the  nature  of  Rickettsia  prowazeki  found  in  the  intestinal  cells  of 
infected  lice. 

3  Toepfer:  ibid.,  1383.  ^  Hanser:  ibid.,  1254. 

6  Toepfer:  Med.  Klin.,  1917,  xiii,  678. 


66  TYPHUS  FEVER 

ganisms  appeared  to  be  identical  with  those  he  had  found  in 
lice  from  typhus  and  Volhynia  fever  cases.  Anaerobic  cultures 
of  these  bacteria  were  successful  if  the  contents  of  the  intes- 
tine of  the  lice  were  placed  in  dextrose  agar,  but  the  colonies 
were  so  small  that  they  were  of  no  value  for  specific  reactions. 
Toepfer  thought  that  the  germs  of  the  nephritic  cases  could  be 
differentiated  from. those  seen  in  typhus  fever  by  the  fact  that 
the  latter  developed  more  markedly  in  the  intestine  of  the  lice. 
He  believed  that  the  three  different  organisms  appear  in  the 
epithelial  cells  of  the  louse.  He  states  that  the  similarity  iti 
appearance  between  the  three  forms  of  bacteria  found  in  lice 
which  he  described  as  the  cause  of  spotted  fever,  of  Volhynia 
fever,  and  of  nephritis  cannot  be  regarded  as  an  argument 
against  their  specificity,  because  in  stained  preparations  the 
bacillus  o£  typhoid  fever  cannot  be  differentiated  from  the 
colon  bacillus  and  several  other  bacteria.  Having  found  similar 
organisms  in  spotted  fever,  in  Yolhynia  fever,  and  in  nephritis, 
the  author  believes  that  the  three  diseases,  which  are  clinically 
so  different,  belong  to  the  same  group.  The  author  thinks  that 
not  only  from  an  aetiological  standpoint  is  this  true,  but  that 
between  nephritis  and  spotted  fever  there  are  histological  re- 
semblances which  he  observed  in  the  study  of  sections  of  the 
skin  of  the  oedematous  tissue  in  nephritis  cases,  a  general  dis- 
turbance of  the  capillaries  being  present  in  both  diseases, 
though  in  spotted  fever  the  capillaries  are  much  more  affected. 
In  the  nephritic  cases,  the  kidneys  are  obviously  particularly 
affected.  The  author  believes  that  the  oedema  and  nephritis 
are  only  partial  results  of  the  infection,  that  the  infection  ex- 
tends from  the  capillaries  over  the  whole  body,  and  that  the 
oedema  and  nephritis  may  b.e  entirely  lacking  in  some  instances. 

In  conclusion,  he  states  that  he  believes  that  war  nephritis  is 
an  infectious  disease  in  which  several  organs  are  attacked,  and 
that  it  is  caused  by  an  inflammatory  and  proliferative  disturb- 
ance of  the  capillary  endothelial  cells,  and  as  a  result  of  this  a 
disturbance  of  the  circulation  follows.  -  ' 

Otto  and  Dietrich  ^  attempted  to  confirm  the  work  of  Rocha- 

^  Otto  and  Dietrich:  Deutsch.  med.  Wchnschr.,  1917,  xliii,  577. 


THE  SERBIAN  EPIDEMIC  67 

Lima  in  relation  to  the  Rickettsia  to  typhus  fever.  Lice  en- 
closed in  small  cardboard  boxes  were  covered  with  a  fine  layer 
of  gauze  and  then  placed  on  the  under  surface  of  the  arm  or  in- 
side the  thigh  of  typhus  fever  patients  at  various  stages  of  the 
disease  and  for  various  periods.  The  lice  placed  on  the  patients 
during  the  febrile  period  became  infected  from  the  fourth  day, 
70  to  80  per  cent  being  infected  if  they  were  allowed  to  feed 
during  the  period  of  seven  to  eight  days.  Of  these  lice  placed 
on  the  patient  towards  the  end  of  the  disease,  only  a  few  be- 
came infected.  The  infection  was  never  found  to  be  heredi- 
tary. In  addition  to  the  usual  bipolar  staining  organisms  found, 
they  also  observed  short,  rodlike,  and  long,  filamentous  forms. 
The  threadlike  forms  were  noted  in  the  case  of  a  louse  taken 
from  a  patient  on  the  fourth  day,  and  were  absent  in  lice  which 
had  fed  for  nine  days.  They  suggest  that  these  forms  may  be 
transition  stages  in  the  life  history  of  the  parasite.  They  suc- 
ceeded in  infecting  lice  with  Rickettsia  by  feeding  them  on 
a  case  of  typhus  fever  without  the  exanthem.  Attempts  to 
transmit  the  infection  to  guinea  pigs  by  the  injection  of  the 
gut  contents  of  infected  lice  were  only  successful  in  a  small 
percentage  of  the  experiments.  The  authors  endeavored 
to  prove  by  agglutination  tests  with  the  serum  of  typhus 
cases  and  an  emulsion  of  the  gut  contents  of  the  infected 
lice,  that  the  Rickettsia  prowazeki  is  the  causative  agent  of 
typhus. 

Wolbach  ^  in  the  study  of  Rocky  Mountain  spotted  fever 
points  out  that  the  essential  lesions  of  spotted  fever  are  found  in 
the  vascular  system  and  that  bacillary  bodies  are  present  in 
large  numbers  in  the  endothehal  cells  of  guinea  pigs  infected 
with  the  virus  of  Rocky  Mountain  spotted  fever  through  the 
bites  of  infected  ticks.  These  bacillary  bodies  had  some  of  the 
characteristics  of  those  previously  described  by  Ricketts,  The 
endothelial  cells  accumulate  in  the  vessel  walls  and  around 
vessels  and  in  the  lymphatics.  The  organisms  are  diplobacilli 
in  character  and  show  polar  staining.  The  staining,  however, 
is  not  that  commonly  seen  with  most  bacteria,  and  indicates 

^  Wolbach:  Jour.  Med.  Research,  1916,  xxxiv,  121. 


68  TYPHUS  FEVER 

that  the  organisms  have  some  of  the  characters  of  spirochaetes. 
All  attempts  at  cultivating  them  have  so  far  failed.  In  another 
paper  Wolbach  ^  reports  the  presence  and  distribution  of  this 
organism  in  experimentally  infected  ticks  {Defmacentor  venus- 
tus,  Banks).  In  the  infected  ticks,  parasites  were  found  similar 
to  those  previously  observed  in  the  tissues  of  monkeys  and 
guinea  pigs,  but  never  in  non-infected  ticks.  The  parasites 
were  present  most  abundantly  in  the  striped  muscle,  also  in  the 
malpighian  tubes,  salivary  glands,  and  ducts  and  brain  ganglia. 
They  were  numerous  in  the  muscle  fibers  of  the  uterus  and 
vagina,  and  have  been  seen  in  the  spermatozoa. 

In  a  third  paper  Wolbach  ^  gives  the  characteristics  of  these 
bodies  as  follows:  ^'In  guinea  pigs  and  monkeys,  in  sections,  a 
minute  rod  in  pairs,  often  lanceolate  and  surrounded  by  a  clear 
zone  or  halo  and  staining  with  difficulty,  occurring  in  large 
mononuclear  cells  (endothelial  cells)  and  smooth  muscle  cells. 
Larger  and  smaller  forms  were  mentioned,  the  former  lance- 
olate, the  latter  occurring  in  smooth  muscle  ceUs.  In  smear 
preparations  from  guinea  pigs  there  were  noted  lanceolate 
paired  forms,  rods  with  irregular  staining,  and  rods  with  chro- 
matoid  granules. 

^'In  ticks,  in  sections  (1)  a  lanceolate  paired  form,  (2)  a 
smaller,  more  slender  rod-shaped  form,  and  (3)  a  minute,  oval- 
coccoid  form;  in  size,  just  within  the  limits  of  resolution  with 
the  best  optical  equipment." 

He  also  describes  in  this  last  paper  the  presence  of  these 
bodies  in  the  lesions  of  the  blood-vessels  in  f  atail  human  cases  of 
Rocky  Mountain  spotted  fever,  and  thinks  they  are  forms  of  a 
new  organism. 

Lopez  ^  in  a  study  of  the  blood  in  typhus  fever  found  the 
intraleucocytal  bodies  discovered  by  Doehle  ^  in  cases  of 
scarlatina  and  also  recognized  by  Preisich  and  others  in  dif- 
ferent diseases.    Lopez  found  these  bodies  in  77  out  of  90  cases 

1  Woibacii:  Jour.  Med.  Research,  1916,  xxxv,  147. 

2  Ibid.,  1918,  xxxvii,  499. 

'Lopez:  Bol.  de  la  Direction  de  Estudios  Biol.,  1917,  ii,  92  (reviewed  in  Trop.  Dis. 
Bull.,  1918,  xii,  108). 

*  Doehle:  Miinchen.  med.  Wchnschr.,  1912,  July  23,  No.  30. 


THE  SERBIAN  EPIDEMIC  69 

of  tjq^hus  fever  examined  by  him.  From  one  to  three  bodies 
were  found  in  one  leucocyte,  and  the  percentage  of  leucocytes 
always  polynuclear  containing  them  varied  from  3  to  80  per 
cent.  They  were  best  stained  by  Giemsa's  method.  He  re- 
marks that  the  blood  must  be  taken  from  well-marked  cases  of 
the  disease  and  at  the  height  of  the  fever  from  the  sixth  to  the 
tenth  day  to  contain  these  bodies.  He  thinks  that  they  may  be 
chlamydozoa,  but  does  not  express  a  decided  opinion  regarding 
their  nature. 

Schmidt  ^  found  in  three  patients  only  out  of  many  cases  of 
five-day  fever  examined,  almond  or  sickle-shaped  organisms  in 
the  blood  which  showed  one  or  two  round  chromatin  bodies  in 
the  interior,  situated  either  peripherally  or  centrally.  They 
were  best  demonstrated  by  Giemsa's  stain.  The  size  varied, 
but  is  comparable  with  that  of  blood  platelets. 

Jungmann  and  Kuczynski  ^  found  in  the  blood  of  typhus 
patients  during  the  first  days  of  the  rash  an  organism  which 
they  believe  to  be  identical  with  Rickettsia  prowazeki  which 
th'ey  had  also  found  in  cases  of  trench  fever.  As  they  had  never 
found  this  organism  in  other  diseases,  they  conclude  there 
must  be  a  relation  between  typhus  and  trench  fever. 

Werner  and  Benzler  ^  in  examining  lice  which  had  fed  upon 
cases  of  febris  quintana  found  in  the  stomach  of  some  of  them 
organisms  resembling  spirochaetes.  In  one,  the  stomach  con- 
tents of  the  louse  showed  bodies  which  could  not  be  distin- 
guished from  those  described  by  Rocha-Lima  in  typhus  and 
by  Toepfer  in  febris  quintana,  and  which  had  previously  been 
cultured  by  him  anaerobically. 

Brumpt  *  studied  72  body  lice  {Pediculus  corporis)  taken 
from  prisoners  of  war  who  had  been  living  in  France  for  some 
time,  and  whose  state  of  health  was  quite  satisfactory.  No 
case  of  typhus  fever  had  ever  been  reported  among  them. 
Twenty-seven  lice  from  the  head  {Pediculus  capitis)  taken 
from  a  healthy  child  at  Rennes  were  also  studied.    Of  the  72 

1  Schmidt:  Deutsch.  med.  Wchnschr.,  1917,  xliii,  682, 

2  Jungmann  and  Kuczynski:  Ztschr.  f.  klin.  Med.,  1917,  Ixxv,  251. 
2  Werner  and  Benzler:  Miinchen  med.  Wchnschr.,  1917,  Ixiv,  695. 

*  Brumpt:  Bull.  Soc.  de  path,  exot.,  1918,  ii,  249. 


70  TYPHUS  FEVER 

body  lice  from  7  healthy  prisoners  of  war,  53  were  found  in- 
fected by  the  microorganism  described  by  Rocha-Lima  under 
the  name  of  Rickettsia  prowazeki,  and  considered  by  him  to  be 
the  causative  agent  of  typhus  fever.    Of  the  53  Hce  with  para- 
sites, 18  were  considerably  infected.    Their  alimentary  canal 
and  a  number  of  the  cells  contained  what  may  be  described  as 
a  pure  culture  of  the  microorganism  in  question.    In  the  35 
remaining  instances,  the  infection  was  slight.    Herpetomonas 
pediculi  was  not  observed.   Brumpt's  investigations  are  so  im- 
portant that  it  is  advisable  to  consider  them  in  greater  detail. 
A  group  of  16  lice  taken  from  healthy  prisoners  of  war  were  all 
found  to  be  infected  with  Rickettsia.    Infection  was  marked  in 
1  case,  moderate  in  13,  and  mild  in  2.    Twenty-four  lice  taken 
at  the  same  time  from  these  same  men  were  fed  upon  the  author 
himself  once  a  day  for  three  days  and  kept  in  the  incubator  at 
a  temperature  of  20°  C.    After  the  third  day  the  surviving  lice 
were  dissected,  and  the  following  results  were  obtained:  severe 
infection  was  found  in  5  cases,  moderate  infection  in  5,  slight 
infection  in  3,  and  no  infection  in  7.   Lice  from  another  healthy 
prisoner  were  fed  upon  the  author.    Thirteen  of  these  surviv- 
ing hce  were  dissected,  when  1  was  found  to  be  strongly  in- 
fected, 5  moderately  infected.    In  2  the  infection  was  shght, 
and  5  showed  no  signs  of  infection.    Eighteen  lice  taken  from 
another  healthy  person  were  fed  on  the  author.    In  4  of  these, 
intense  infection  was  found,  in  1  moderate,  2  slight,  and  in  5, 
no  infection  was  present.  Lice  were  taken  from  another  healthy 
subject  and  fed  on  the  author.    Of  the  6  lice  which  survived,  5 
showed  severe  infection,  and  1  no  infection.    Lice  taken  from 
another  healthy  prisoner  of  war  were  fed  on  the  author  for  four 
days.    The  9  surviving  lice  were  dissected  with  the  result  that 
in  2  instances  a  severe  infection  was  present,  in  2  a  moderate 
one,  and  in  5  no  infection  was  found.    The  microorganism  in 
question  was  found  practically  as  a  pure  culture  in  the  dejecta 
of  the  louse.   No  sign  of  infection  was  found  in  the  alimentary 
canal  of  27  head  hce  taken  from  a  healthy  child.    The  germs 
found  in  73  per  cent  of  the  lice  taken  from  healthy  individuals 
were  either   elliptical  in  shape,   occasionally  spherical,   but 


THE  SERBIAN  EPIDEMIC  71 

generally  coccobacillary  in  form.  There  is  always  a  predomin- 
ating shape  in  the  Rickettsia  encountered  in  one  louse.  They 
are  either  practically  round  or  slightly  elongated.  The  or- 
ganisms stained  like  spirochaetes  in  the  blood.  They  showed 
intensely  tinted  poles,  joined  by  a  faintly  stained  central  por- 
tion. The  average  dimensions  of  the  organism  varied  between 
.4  and  .6  /x  for  the  round  forms,  1.2  to  1.4  /x  in  length,  .5  ju  in 
width  for  the  average  forms,  1.65  m  to  2  m  long  by  .6  m  wide  for 
the  largest  forms.  The  last  were  seldom  met  with.  The  author 
never  observed  the  parasites  in  chains.  He  concludes  that  his 
observations  lead  him  to  identify  the  organisms  found  in  lice 
taken  from  healthy  people  with  those  previously  described  by 
Rocha-Lima  under  the  name  of  Rickettsia  prowazeki.  Seventy 
of  these  lice  were  fed  upon  himself  and  53  were  found  infected 
with  the  above  described  organism;  but  he  remained  healthy. 
The  author  points  out  that  although  this  organism  in  question 
which  has  not  been  cultivated  may  be  encountered  in  the  blood 
or  in  the  organs  of  some  of  the  patients,  it  need  not  for  this  rea- 
son be  considered  the  pathogenic  agent  of  typhus  fever  as  it 
may  have  been  inoculated  by  the  louse  and  have  no  path- 
ogenic action.  The  author  points  out  that  the  lice  infected  by 
the  coccobacilli  retain  the  infection  during  their  entire  life. 
The  lice  carrying  the  typhus  virus  are  active  from  the  eighth  to 
the  tenth  day. 

Arkwright,  Bacot,  and  Duncan  ^  reported  that  in  their  in- 
vestigations they  used  a  clean  stock  of  lice  bred  in  captivity 
and  kept  under  observation  for  over  three  years.  They  fed 
these  normal  lice  on  trench  fever  patients  both  during  and  after 
febrile  periods.  Either  the  feeding  on  the  infected  person  was 
for  one  day  only,  followed  by  feeding  on  a  healthy  man,  or 
after  the  first  infecting  meal  the  lice  were  fed  regularly  on  the 
same  or  another  infected  man,  and  between  the  feedings  the 
lice  were  kept  in  an  incubator  at  a  temperature  of  about  27°  C, 
or  in  an  inside  pocket.  They  were  later  examined  micro- 
scopically either  by  films  made  from  the  excreta,  or  from  the 
gut  contents,  or  in  microscopic  serial  sections.    The  films  were 

1  Arkwrightj  Bacot,  and  Duncan:  Brit.  Med.  Jour.,  1918,  ii,  307. 


72  TYPHUS  FEVER 

treated  with  acid  alcohol  to  fix  and  to  remove  haemoglobin 
debris,  and  were  then  stained  with  Giemsa's  solution.  The 
following  conclusions  were  reached  by  them,  confirming  and 
extending  the  work  of  previous  workers: 

1.  If  a  box  of  lice  is  fed  on  a  trench  fever  patient,  and  the 
excreta  collected  after  a  period  of  about  ten  days,  large  num- 
bers of  Rickettsia  bodies  can  almost  invariably  be  found  in 
films.  Smears  of  the  guts  of  lice  from  such  a  box  contain  large 
numbers  of  these  bodies  after  about  the  same  interval  of  time. 
Of  253  specimens  from  boxes  of  lice  which  had  been  fed  on 
trench  fever  patients  at  least  five  days  previously,  150  showed 
Rickettsia  bodies,  83  gave  a  negative  result,  and  20  a  doubtful 
result. 

2.  The  excreta  from  sixteen  boxes  of  lice  which  were  ex- 
amined daily  after  an  infecting  meal  showed  Rickettsia  bodies 
for  the  first  time  twice  on  the  fifth  day,  three  times  on  the 
seventh,  three  times  on  the  eighth,  four  times  on  the  ninth, 
three  times  on  the  tenth,  and  once  on  the  twelfth  day  from  the 
first  infecting  meal.  When  first  seen  only  small  numbers  were 
noted  in  the  films,  but  three  or  four  days  later  enormous  num- 
bers appeared.  These  experiments  show  that  after  an  infecting 
feed  there  is  a  period  during  which  these  bodies  are  not  recog- 
nizable on  account  of  their  small  numbers,  or  of  some  difference 
in  form.  When  a  box  has  once  become  infected  with  Rickettsia 
the  excreta  collected  from  it  continue  to  show  the  bodies  for 
two  or  three  weeks,  or  till  the  lice  which  partook  of  the  infect- 
ing feed  are  dead. 

3.  All  lice  from  an  infected  box  do  not  show  Rickettsia; 
only  a  small  proportion  do  so  in  the  first  week;  the  proportion 
increases  until  after  two  and  a  half  to  three  weeks  the  great 
majority  show  these  forms.  Experiments  at  Hampstead  have 
also  made  it  probable  that  after  the  same  time  a  considerable 
proportion  of  lice  are  infective. 

4.  Trench  fever  patients  can  infect  lice  with  Rickettsia 
bodies  during  the  fever,  between  the  attacks,  or  even  several 
weeks  after  an  attack  during  a  non-febrile  period. 

5.  Normal  lice,  fed  on  persons  who  have  not  been  exposed  to 


THE  SERBIAN  EPIPEMIC  73 

trench  fever  infection,  have  remained  free  from  Rickettsia.  Of 
245  specimens  from  22  boxes  fed  on  seven  healthy  persons  only 
one  specimen  of  excreta  was  found  to  contain  forms  which 
closely  resembled  Rickettsia  microscopically.  It  is  not  sur- 
prising, considering  the  difficulty  in  recognizing  such  small 
bodies  by  their  morphology,  that  occasional  errors  should  oc- 
cur. Four  other  specimens  from  two  boxes  showed  these 
bodies,  but  they  were  being  fed  on  a  man  who  had  been  working 
with  infected  excreta  in  the  laboratory  for  five  weeks,  and  had 
also  been  feeding  infected  lice  on  himself  for  the  same  period. 
He  developed  trench  fever  three  days  after  that  upon  which 
the  first  one  of  the  four  positive  specimens  was  found.  It  is 
most  probable,  therefore,  that  he  had  been  infected  for  some 
days  before  the  bodies  were  observed  in  the  lice. 

They  further  pointed  out  that  Rickettsia  bodies  are  very 
small  and  approach  the  limits  of  filterability  of  a  Berkefeld 
filter.  In  their  experiments  the  Rickettsia  bodies  did  not  make 
their  appearance  in  lice  till  about  the  fifth  to  the  twelfth  day 
after  an  infecting  meal.  In  53  experimental  inoculations  of 
volunteers,  the  lice  or  excreta  of  lice  used  as  the  virus  were  also 
examined  microscopically.  In  every  case  the  lice  had  pre- 
viously been  fed  on  a  trench  fever  patient.  Twenty-seven  of 
the  specimens  showed  Rickettsia  bodies  and  caused  trench 
fever;  10  specimens  did  not  show  Rickettsia  bodies  and  did  not 
cause  trench  fever;  1  specimen  showed  Rickettsia  bodies  but 
did  not  cause  trench  fever;  2  specimens  did  not  show  Rickettsia 
bodies  but  caused  trench  fever;  4  specimens  gave  doubtful 
results  microscopically,  or  the  inoculation  was  followed  by 
fever  of  a  doubtful  nature;  9  specimens  showed  Rickettsia 
bodies  but  did  not  cause  trench  fever.  The  authors  thought 
this  was  because  the  virus  had  been  heated  or  treated  with 
disinfectant,  or  because  the  volunteer  inoculated  had  recently 
passed  through  an  attack  of  trench  fever  and  was  probably 
immune.  They  believe  the  agreement  between  the  demon- 
strable presence  of  the  virus  and  the  Rickettsia  bodies  is  very 
close,  and  that  a  very  close  correlation  has  been  shown  to  exist 
between  the  presence  of  Rickettsia  bodies  in  lice  or  the  excreta 


74  TYPHUS  FEVER 

of  lice  and  the  virulence  of  these  materials  when  inoculated  into 
man. 

Most  of  the  observers  so  far  mentioned  in  this  article,  who 
have  regarded  the  Rickettsia  as  representing  microorganisms, 
apparently  have  believed  that  they  were  either  chlamydozoal 
or  protozoal  in  character  or  at  any  rate  were  of  a  non-bacterial 
nature.  Other  investigators,  however,  have  believed  the  bodies 
described  as  Rickettsia  are  really  bacteria,  and  more  recently 
it  has  been  suggested  that  the  bacillary  forms  are  identical 
either  with  the  bacillus  described  by  Plotz  as  the  cause  of 
typhus  fever  or  with  the  Bacillus  proteus  X  19,  believed  by 
others  to  be  the  cause  of  this  disease. 

Rabinowitsch  Mn  1914  refers  to  the  fact  that  in  1908  he  dis- 
covered the  causative  agent  of  typhus  naming  the  organism 
Diplohacillus  exanthematicus.  In  fresh  cultures  the  organism 
practically  always  appeared  as  a  diplobacillus.  Degeneration 
forms  only  developed  in  old  cultures.  In  fresh  cultures,  the 
organism  was  always  Gram-positive,  while  in  old  ones  it  be- 
came Gram-negative.  Cultures  were  best  obtained  the  author 
says  by  using  a  medium  consisting  of  equal  parts  of  ascitic  broth 
mixed  with  4  per  cent  glycerin.  One  hundred  c.c.  of  this  mix- 
ture were  to  be  inoculated  with  from  3  to  5  c.c.  of  the  blood  of 
a  typhus  patient  obtained  shortly  before  the  crisis.  After  the 
crisis  the  organism  seemed  to  disappear  from  the  blood.  He 
points  out  that  guinea  pigs  can  be  infected  both  by  the  injec- 
tion of  cultures  and  by  the  blood  of  typhus  patients,  the  incuba- 
tion period  varying  from  5  to  37  days.  He  examined  the 
blood  of  58  typhus  patients.  In  the  films  stained  deeply  with 
Giemsa's  solution  he  found  peculiar,  very  deeply  staining 
leucocytes  which  had  a  very  basophilic  protoplasm.  They 
often  constituted  from  3  to  8  per  cent  of  the  white  cells.  He 
thought  that  these  might  furnish  a  means  of  diagnosing  the 
infection. 

Mueller  ^  made  bacteriological  examinations  of  various  cases 
of  typhus  occurring  amongst  the  Bosnians  in  the  Marine  Hos- 

1  Rabinowitsch:  Berl.  klin.  Wchnschr.,  1914,  li,  Part  2,  1458. 

2  Mueller:  Miinchen.  med.  Wchnschr.,  1913,  Ix,  Part  1,  1364. 


THE  SERBIAN  EPIDEMIC  75 

pital  of  San  Bartolomeo,  Trieste.  In  Giemsa-stained  prepa- 
rations, diplococci,  cocci,  and  ovoid  rod-shaped  bodies  were 
found  present  in  the  blood  of  all  the  cases  of  typhus  examined, 
and  also  in  four  patients  that  no  longer  showed  any  fever.  The 
cultural  examination  of  the  blood  of  eleven  patients  gave  five 
positive  results,  in  each  case  a  diplobacillus  developing  in  the 
broth.  Attempts  to  cultivate  the  organisms  on  ascitic  agar 
succeeded  only  three  times.  The  isolated  cultures  seemed  to  be 
identical  with  those  obtained  by  Fuerth  from  cases  of  typhus  in 
Tsingtau.  The  organisms  were  non-motile  rods  which  readily 
round  off  into  coccoid  forms  in  the  various  culture  media.  The 
pathogenicity  of  the  culture  organism  towards  animals  was 
only  very  slight.  When  mice  were  inoculated  with  enormous 
doses,  they  succumbed  within  24  hours,  and  the  diplobacilli 
were  found  in  every  part  of  the  body.  A  rabbit  showed  a  single 
parasite  after  an  incubation  period  of  seven  days.  On  the  other 
hand,  three  monkeys  inoculated  with  the  cultures  remained 
normal.  According  to  the  author  there  can  be  no  doubt  that 
this  diplobacillus  isolated  at  San  Bartolomeo  is  identical  with 
the  organism  described  by  Rabinowitsch  and  others. 

Olitsky,  Denzer,  and  Husk  ^  state  it  is  their  opinion  that  the 
Bacillus  typhi  exanthematici  described  by  Plotz  corresponds 
to  the  organism  described  by  Rocha-Lima  as  Rickettsia  pro- 
wazeki.  They  point  out  that  while  Rocha-Lima  found  the 
Rickettsia  to  be  Gram-negative,  and  that  the  bacillus  described 
by  Plotz  was  Gram-positive,  that  the  organism  described  by 
Plotz  may  be  sometimes  Gram-negative  ^  in  the  first  subcul- 
tures made  from  lice  or  in  smears  made  directly  from  typhus 
infected  lice,  as  has  been  shown  by  Baehr  and  Plotz, ^  and 
Baehr  and  Plotz  have  reported  the  occurrence  of  the  Plotz  or- 
ganism in  infected  lice  and  have  ^own  it  under  anaerobic 
conditions.  They  have  also  produced  typhus  fever  by  the  in- 
jection of  infected  lice.  For  these  reasons  they  think  the 
Rickettsia  and  the  Plotz  bacillus  are  identical.   They  think  the 

1  Olitsky,  Denzer,  and  Husk:  Jour.  Am.  Med.  Assn.,  1917,  Ixviii,  1165. 

2  Baehr  and  Plotz:  Jour.    Infect.  Dis.,  1917,  xx,  201. 
^  Olitsky,  Denzer,  and  Husk:  ibid.,  1916,  xix,  811. 


76  TYPHUS  FEVER 

reason  that  the  bodies  described  under  the  name  of  Rickettsia 
have  not  been  cultivated  by  other  observers  is  owing  to  the 
fact  that  improper  methods  have  been  used.  Popoff  ^  beUeves 
that  the  Rickettsia  prowazeki  described  by  Rocha-Lima  is  the 
same  organism  as  the  bacillus  described  by  Plotz  as  the  cause 
of  typhus  fever. 

Kuczynski  ^  carried  out  his  experiments  with  a  view  to 
determining  the  role  played  by  Bacillus  proteus  Xl9m  typhus 
fever.  Seventy-two  body  lice  were  artificially  infected  with  a 
pure  culture  of  this  organism.  After  examining  the  lice  which 
survived  for  72  hours,  he  came  to  the  conclusion  that  Bacil- 
lus X 19  and  Rickettsia  are  not  identical,  and  that  it  is  possible 
that  infection  with  Rickettsia  prevents  the  development  of 
X  19  under  natural  conditions.  He  found  that  X  19  developed 
in  the  louse  and  believes  that  the  rod  and  threadlike  forms  de- 
scribed by  other  authors  as  developmental  stages  of  Rickettsia 
are  probably  stages  in  the  development  of  X  19.  He  fed  these 
experimental  lice  upon  himself  and  as  he  remained  healthy  he 
came  to  the  conclusion  that  X  19  is  not  pathogenic.  In  another 
paper  ^  he  made  histological  investigations  upon  material  from 
typhus  fever  cases.  .  .    , 

In  the  petechiae  of  typhus  he, was  not  able  to  find  anything 
which  appeared  definitely  to  be  the  causative  organism.  In  the 
investigation  of  sections  of  the  liver  in  the  endothelial  cells  of 
the  capillaries  and  in  free  phagocytic  cells,  two  different  micro- 
organisms were  found.  First,  large  bacilli-like  bacteria  which 
appeared  similar  in  appearance  to  the  proteus  bacillus;  and 
second,  bodies  in  sections  stained  by  Giemsa's  solution,  re- 
sembling the  Rickettsia  as  described  by  Rocha-Lima  in  the 
intestinal  cells  of  lice.  The  author  believes  he  could  differen- 
tiate these  bodies  from  other  histologic  elements  by  their 
intracellular  position,  their  spherical  grouping,  and  their  inten- 
sive stain. 

1  Popoff:  Med.  KUn.,  1917,  No.  14,  p.  397. 

2  Kuczynski:  Arch.  f.  Protistenkunde,  1918,  xxxviii,  376. 

3  Ibid. :  Centralbl.  f.  allg.  Path.  u.  path.  Anat.,  1918,  xxix,  279.  • 


THE  SERBIAN  EPIDEMIC 


77 


The  following  table  summarizes  the  reports  of  different  in- 
vestigators with  reference  to  Rickettsia  bodies  in  connection 
with  disease. 


Year  Investigator 

1909    Ricketts 


1910    Ricketts  and  Wilder 


1910    Gavin  and  Girard 

1912  Doehle 
Preisich 

1913  Prowazek 


1913  MueUer 

1914  Sergent,  Foley,  and 
Vialatte 


1914    Nicolle,  Blanc,  and 
Conseil 


1914    Rabinowitsch 


1915    Proescher 


1916    Dorendorf 


Rickettsia  bodies  or  organisms  resembling  them  found  in 

Bacilli  in  blood  of  guinea  pigs  and  monkeys  infected 
with  blood  from  Rocky  Mountain  spotted  fever 
cases.  Also  seen  in  blood  of  man,  and  in  female 
tick  (Dermacent&r  occidentalis)  and  in  eggs  of  these 
ticks  fed  upon  infected  guinea  pigs. 

Studies  in  Mexico.  Bacilli  in  blood  of  typhus  pa- 
tients. Also  in  dejecta  and  various  organs  of  lice 
fed  on  typhus  patients.  Occasionally  found  in 
faeces  and  intestinal  contents  of  normal  lice. 

Blood  of  patients  in  Mexico.  Significance  of  bodies 
obscure. 

Discovered  intraleucocytal  bodies  in  scarlatina  cases. 

Recognized  same  bodies  in  other  diseases. 

Blood  of  51  typhus  cases  in  Belgrade.  In  examina- 
tion of  sections  of  organs  of  typhus  cases,  tra- 
choma-like bodies  observed  in  endothelial  cells  of 
heart,  lung,  liver,  kidney.  One  infected  louse  con- 
tained coccoid  bodies  and  diplococcus  forms. 

Blood  of  typhus  fever  cases.  Inoculated  mice  and 
rabbit. 

Lice  living  only  on  the  sick,  never  in  hce  living  on 
healthy  people,  or  recurrent  fever  patients,  in 
Algeria.  Found  especially  in  bloody  fluid  of  diges- 
tive tract  of  the  lice.  A  number  of  such  lice  fed  on 
healthy  individuals  and  proportion  of  microbes 
seen  became  much  larger.  Could  not  cultivate 
microorganism  on  artificial  media. 

Tunis,  in  5  per  cent  of  lice  collected  in  districts  free 
from  typhus  for  two  years.  Lice  fed  on  typhus 
cases  are  constantly  infectious  on  ninth  and  tenth 
day,  not  before  the  eighth.  Organisms  not  detected 
in  blood  and  organs*  of  guinea  pigs  infected  with 
typhus. 

In  1908  discovered  Diplobacillus  exanthematicus  as 
the  causative  agent  of  typhus.  Organism  found  in 
blood  of  typhus  patients. 

Blood  smears  from  nine  typhus  cases  showed  bodies 
in  endothelial  cells  from  blood-vessels.  Very  few 
seen  in  plasma  and  in  polynuclear  leucocj^tes. 
These  bodies  not  found  in  normal  blood  or  in 
blood  from  cases  of  measles,  mumps,  scarlet  fever, 
cholera,  relapsing  fever. 

Blood  of  typhus  fever  cases  in  Serbia  examined,  and 
organisn^s  described  by  Prowazek  discovered  in  all 
cases  examined  during  febrile  stage  —  found  in 
plasma  and  in  polymorphonuclear  and  mononu- 
clear leucocytes. 


78 


TYPHUS  FEVER 


Year  Investigator 

1916    Stempell 
1916    Lipschuetz 


1916    Csernel 
1916    ZoUenkopf 


1916     Rocha-Lima  and 
Prowazek 


1916     Rocha-Lima 


1916    Wolbach 


1916    Wolbach 


1916    Noeller 


Rickettsia  bodies  or  organisms  resembling  them  found  in 

Among  the  enigmatic  parasites  in  the  intestinal 
epithelium  in  dissected  lice  collected  frohi  sick 
people. 

Polymorphonuclear  leucocytes  in  blood  from  typhus 
cases;  twenty-three  examined,  eighteen  were  posi- 
tive. These  bodies  not  found  in  control  prepara- 
tions from  typhoid  fever  and  variola  cases,  or  in 
normal  blood  preparations. 

Typhus  blood. 

In  describing  a  new  disease  resembling  intermittent 
fever  (probably  Volhynia  fever)  found  changes  in 
red  cells.  Not  found  in  preparations  taken  after 
the  fever. 

Investigations  at  Prison  Camp,  Kottbus,  95  per  cent 
of  lice  taken  from  sick  people  were  infected  by 
parasitic  microorganism.  Organisms  found  in 
contents  of  alimentary  canal,  and  especially  in 
epithelial  cells  of  alimentary  tract.  Not  found  in 
lice  living  on  healthy  subjects.  Non-infected  lice 
placed  on  sick  patients  became  infected.  This 
parasite  found  in  man  only  in  the  leucocytes. 

In  1914  (December)  in  streak  preparations  made 
from  lice  fed  on  typhus  cases,  found  large  numbers 
of  bodies.  Recognized  by  Prowazek  as  the  same 
as  seen  by  him  in  1913  in  preparation  from  in- 
fected louse.  In  examination  of  sections  of  lice 
from  typhus  cases,  and  of  normal  lice,  bodies  found 
in  large  numbers  in  cells  of  alimentary  canal  and 
in  salivary  glands  of  infected  lice;  not  in  normal 
lice.  Seventeen  out  of  eighteen  lice  from  a  sick 
patient  were  infected.  Rickettsia  appeared  in 
cells  of  intestine  of  lice  on  fourth  or  fifth  day. 
Louse  fed  on  typhus  patient  showed  Rickettsia 
four  days  afterwards. 

Bacillary  bodies  are  present  in  large  numbers  in  en- 
dothelial cells  of  guinea  pigs  infected  with  the 
virus  of  Rocky  Mountain  spotted  fever  through 
the  bites  of  infected  ticks. 

Organism  found  in  experimentally  infected  ticks, 
similar  to  those  previously  seen  in  tissues  of  mon- 
keys and  guinea  pigs,  but  never  in  non-infected 
ticks.  Parasites  most  abundant  in  striped  muscle, 
malpighian  tubes,  salivary  glands,  and  ducts  and 
brain  ganglia.  Numerous  in  muscle  fibers  of 
uterus  and  vagina,  and  seen  in  the  spermatozoa. 
Also  in  lesions  of  blood-vessels  in  fatal  human 
cases  of  Rocky  Mountain  spotted  fever. 

Lice  from  pigs  transferred  from  infected  guinea  pigs 
to  pig  blood. 


THE  SERBIAN  EPIDEMIC 


79 


Year  Investigator 

1916  Toepfer 


1916  Toepfer 


1916  Hanser 

1917  Munk  and  Rocha- 
Lima 


1917    Toepfer  and  Schues- 
sler 


1917    Toepfer 


1917     Otto  and  Dietrich 


Rickettsia  bodies  or  organisms  resembling  them  found  in 

Blood  of  Volhynia  fever.  Also  in  lice  from  typhus 
fever  patients. 

Lice  from  typical  Volhjaiia  fever  contained  bodies  in 
alimentary  tract  similar  to  typhus  fever  organism. 
Bodies  both  free  and  inside  the  cells. 

Examined  smears  and  sections  of  500  lice.  Con- 
firmed his  former  observations  regarding  organism 
in  infected  hce. 

Same  parasite  found  in  lice  from  heads  of  patients 
and  in  artificially  infected  normal  lice  of  this  spe- 
cies by  placing  them  upon  the  sick.  Smears  from 
lice  fed  on  typhus  blood  contained  organism. 

Described  intracellular  diplobaciUi  in  tissues  of 
typhus  patients. 

Confirms  Toepfer's  discovery  of  forms  in  intestinal 
cells  of  lice  fed  on  typhus  patients. 

Found  diplobacillus  in  blood  of  Volhynia  fever  cases, 
but  also  found  same  in  blood  from  patients  with 
other  diseases  or  even  from  healthy  ones. 

Munk  made  70  experiments  on  patients  diagnosed 
as  Volhynia  fever  cases,  —  51  positive  for  R. 
pediculi,  11  negative,  6  doubtful.  Among  nega- 
tives were  some  typical  cases. 

Among  33  control  tests,  26  were  negative  and  6  in- 
fected same  as  lice  from  Volhynia  fever  cases. 
These  6  cases  upon  which  the  lice  were  fed  which 
proved  positive  for  Rickettsia  were  3  malaria,  1 
bladder  disease,  1  bronchitis,  1  inguinal  hernia. 
One  normal  gave  rise  to  strongly  infected  lice. 

Rocha-Lima  and  Korbsch  attempted  propagation  of 
Volhynia  fever  with  lice,  but  not  successful 
although  lice  were  strongly  infected. 

In  400  lice  which  had  fed  on  35  patients,  bacteria- 
like  organisms  were  found  in  the  infected  Hce. 
Organisms  found  constantly  in  intestinal  canal  of 
lice  removed  frpm  typhus  patients  and  often  in 
cells  of  alimentary  tract.   Control  lice  fed  on  other 

■  .  individuals  than  those  suffering  with  tj^phus  fever 
remained  free.  Organism  found  only  in  lice  fed  on 
blood  of  typhus  patients  during  febrile  (not  post- 
febrile) period. 

In  article  on  war  nephritis  describes  similar  or- 
ganisms to  those  seen  in  lice  fed  on  cases  of  typhus 
or  Volhynia  fever.  Found  similar  organisms  in  3 
diseases,  i.  e.,  spotted  fever,  Volhynia  fever,  and 
nephritis. 

In  lice  placed  on  patients.  Infection  not  hereditary. 
They  infected  lice  with  Rickettsia  by  feeding  them 
on  a  case  of  typhus  fever  without  the  exanthem. 


80  TYPHUS  FEVER 

Year  Investigator  Rickettsia  bodies  or  organisms  resembling  them  found  in 

1917    Lopez  Blood  of  typhus  fever,  found  same  intraleucocyi;al 

bodies,  in  77  out  of  90  cases.  Blood  must  be  taken 
from  well-marked  cases  and  at  the  height  of  the 
fever,  to  contain  these  bodies. 

1917    Schmidt  Organisms  found  in  3  cases  only,  out  of  many  cases  of 

five-day  fever  examined. 

1917    Jungmann  and  Blood  of  typhus  patients  during  first  days  of  the 

Kuczynski  rash,  and  also  in  trench  fever.    Had  never  found 

organism  in  other  diseases. 

1917  Werner  and  Benzler     In  the  stomach  of  lice  fed  upon  cases  of  fehris 

quintana. 

1918  Brumpt  53  out  of  72  body  lice  taken  from  healthy  prisoners  of 

war,  pure  culture  found  in  the  alimentary  canal 
and  in  some  cells. 
16  lice  from  healthy  prisoners  of  war  were  all  in- 
fected, etc. 

1918    Arkwright,  Bacot,         Lice  fed  on  trench  fever  patients.  Normal  lice  fed  on 
and  Duncan  persons  not  exposed  to  trench  fever  infection  re- 

mained free  from  Rickettsia. 

1918    KuCzynski  In  the  petechiae  of  typhus  cases,  in  sections  of  liver 

in  the  endothelial  cells  of  the  capillaries,  and  in  free 
phagocytic  cells. 

Our  studies  regarding  the  occurrence  of  Rickettsia  bodies  in 
lice  which  have  fed  upon  healthy  persons  have  confirmed  those 
of  a  number  of  observers  already  referred  to.  Lice  collected 
from  healthy  men  in  different  parts  of  France,  where  neither 
typhus  fever  nor  trench  fever  were  present,  were  often  found  to 
contain  Rickettsia  in  their  dejecta:  from  20  to  40  per  cent  of 
such  lice  examined,  collected  in  different  groups,  revealing  these 
bodies.  In  some  of  these  normal  lice,  microscopical  examina- 
tion of  the  excreta  or  material  from  the  alimentary  tract 
showed  them  to  be  severely  infected  with  Rickettsia  bodies. 
Others  were  only  moderately  or  very  slightly  infected,  while  in 
the  remaining  no  definite  Rickettsia  were  observed.  Obviously 
from  a  microscopical  examination,  it  is  sometimes  extremely 
difficult  to  say  whether  these  bodies  are  not  present  in  small 
numbers  in  the  lice.  Plate  XXI,  Figures  1  and  2,  demonstrate 
the  Rickettsia  bodies  in  the  excrement  of  normal  lice.^    There 

1  These  photomicrographs  were  kindly  made  at  the  Pasteur  Institute  by  Dr.  P. 
Jeantet,  who  is  in  charge  of  the  photomicrographic  work  of  this  Institute.  I  wish  to  ex- 
press my  thanks  to  both  Dr.  Roux,  the  Director  of  the  Pasteur  Institute,  and  to  Dr. 
Jeantet,  for  this  courtesy. 


Figs.  1  and  2.     Rickettsia  bodies  in  the  excrement 

OP   NORMAL   lice 

{Reprinted  with  permission  of  Paul  B.  Hoeber,  Publisher  of 
Osier  Anniversary  Volume) 


PLATE  XXI 


THE  SERBIAN  EPIDEMIC  81 

was  not  opportunity  to  search  for  them  in  the  intestinal  epi- 
thelium. The  lice  are  referred  to  as  normal  because  they  pro- 
duced no  disease  either  in  their  original  host  from  which  they 
were  collected,  or  when  they  were  placed  upon  or  fed  upon 
other  healthy  individuals. 

A  critical  examination  of  the  literature  regarding  the  relation 
of  Rickettsia  to  disease  reveals  the  fact  that  these  bodies  have 
been  found  in  lice  which  have  fed  upon  cases  of  typhus  fever, 
Volhynia  fever,  trench  fever,  war  nephritis,  malaria,  bron- 
chitis, inflammation  of  the  bladder,  and  inguinal  hernia,  as 
well  as  in  a  large  number  of  lice  collected  in  different  parts  of 
the  world  which  have  fed  only  on  healthy  people  in  whom  they 
produced  no  disease.  Rocha-Lima  maintains  that  in  lice, 
Rickettsia  prowazeki,  which  is  regarded  by  him  as  the  prob- 
able cause  of  typhus  fever,  differs  from  Rickettsia  pediculi 
(which  is  found  in  lice  not  infected  with  the  virus  of  typhus)  in 
that  the  latter  does  not  occur  normally  in  the  epithelium  of  the 
alimentary  canal  of  the  louse.  However,  Toepf er,  Brumpt,  and 
others  have  reported  the  presence  of  Rickettsia  in  the  intesti- 
nal epithelial  cells  of  lice  fed  upon  healthy  individuals  or  in 
those  fed  upon  Volhynia  fever  cases,  or  cases  of  war  ne- 
phritis. Rickettsia  have  also  been  found  in  ticks  that  have  fed 
upon  cases  of  Rocky  Mountain  spotted  fever.  They  have  in 
addition  been  observed  in  the  blood  of  man  in  a  number  of  dis- 
eases, for  example,  in  typhus  fever,  in  Rocky  Mountain  spotted 
fever,  in  Volhynia  fever,  and  trench  fever.  Rocha-Lima  also 
believes  that  he  has  seen  in  the  blood  of  healthy  persons  similar 
bodies  to  those  observed  in  the  blood  of  Volhynia  fever  by 
other  investigators,  and  described  by  them  under  the  name  of 
Rickettsia. 

Further,  when  we  come  to  consider  the  aetiological  signifi- 
cance of  Rickettsia  in  human  disease,  it  is  apparent  from  the 
evidence  already  presented  in  this  article  that  not  one  of  the 
three  classical  postulates  regarded  necessary  for  the  proof  of 
the  aetiological  factor  of  an  infectious  disease  has  yet  been 
demonstrated  for  the  Rickettsia.  (1)  They  have  not  been 
found  in  every  case  of  the  disease  they  have  been  said  to  be  the 


82  TYPHUS  FEVER 

cause  of;   moreover  they  have  been  found  in  connection  with 
other  diseases  than  the  one  it  is  maintained  they  give  rise  to. 

(2)  They  have  not  been  isolated  and  grown  in  pure  culture.^ 

(3)  The  disease  which  they  are  said  to  be  the  cause  of  has  not 
been  produced  by  the  inoculation  of  such  culture. 

It  seems  very  probable  that  the  Rickettsia  bodies  are  micro- 
'organisms,  but  as  they  have  been  found  in  lice  from  patients 
with  so  many  different  diseases,  as  well  as  in  lice  from  healthy 
individuals,  obviously  no  specificity  for  them  could  be  justly 
claimed  without  further  investigation.  It  is  true  that  Rocha- 
Lima,  Toepfer,  and  Olitsky,  Denzer  and  Husk  report  the  pro- 
duction of  typhus  infection  in  animals  by  the  inoculation  of  the 
contents  of  the  alimentary  tract  of  infected  lice.  In  this  con- 
nection Rocha-Lima  claimed  that  the  disease  developed  in  the 
inoculated  animal  because  the  Rickettsia  were  present  in  the 
lice  used  for  the  injections,  while  on  the  other  hand,  Olitsky, 
Denzer,  and  Husk  claim  the  disease  developed  because  the 
Plotz  baciUus  was  present  in  the  lice  used  in  the  inoculation  of 
the  animals.  Obviously  we  can  draw  no  definite  conclusions 
from  these  experiments  save  that  the  infecting  agent  visible  or 
invisible  was  present  in  the  lice.  Nothing  can  be  said  from  them 
regarding  the  definite  nature  of  the  infecting  agent.  Sergent, 
Foley,  Vialatte,  and  Brumpt  all  pointed  out  that  the  Rickett- 
sia might  merely  accompany  the  infectious  agent. 

Observations  and  experiments  recently  made  in  connection 
with  trench  fever  may  be  of  interest  in  the  study  of  Rickettsia. 
In  relation  to  the  aetiology  of  trench  fever,  as  has  been  the  case 
in  the  history  of  most  infectious  diseases,  a  number  of  widely 
differing  microorganisms  have  previously  been  described  as  its 
cause,  but  none  of  these  claims  have  been  substantiated,  and 
although  very  extensive  studies  have  been  made  by  a  large 
number  of  observers,  it  is  still  a  question  whether  the  organism 
causing  trench  fever  has  yet  been  definitely  seen  in  man  either 
with  the  microscope  or  the  ultramicroscope.    Our  experiments 

1  Kuczynski  (Med.  Klin.,  1920,  xvi,  pp.  706,  733,  759)  has  since  reported  to  have  cul- 
tivated R.  prowazeki  in  blood  plasma  modified  to  resemble  human  tissue  Ijrmph  in  cel- 
loidin  capsules  in  the  abdominal  cavity  of  guinea  pigs.  He  has  also  claimed  to  have  pro- 
duced typhus  infection  in  guinea  pigs  with  such  cultures. 


THE  SERBIAN  EPIDEMIC  83 

carried  on  in  relation  to  the  aetiology  of  trench  fever  have  since 
shown  that  the  causative  organism  of  this  disease  is  under  cer- 
tain circumstances  filterable  and  that  it  bears  some  resem- 
blance in  its  behavior  to  the  filterable  virus  of  hog  cholera.^ 
Our  work  regarding  the  filterable  qualities  of  the  virus  of  trench 
fever  has  recently  been  confirmed  by  Major  General  Sir  John 
Rose  Bradford,  Captain  E.  F.  Bashford,  and  Captain  J.  A. 
Wilson.^  The  organism  causing  trench  fever  being  so  minute 
is  obviously  separated  only  with  great  difficulty  from  the  sur- 
rounding structures  in  the  media  in  which  it  occurs  naturally. 
Thus,  while  we  have  demonstrated  that  the  virus  of  trench 
fever  is  present  in  the  plasma  of  the  blood  of  trench  fever 
cases,  in  the  febrile  stages  of  the  disease  it  is  frequently  very 
difficult  to  separate  it  from  the  blood  corpuscles  themselves 
by  repeated  washings  of  these  with  saline  solution.^  Also  in  the 
alimentary  canal  of  the  louse  fed  upon  trench  fever  cases  and 
in  infected  louse  excrement,  the  virus  on  account  of  its  minute 
size  must  be  closely  intermingled  with  other  cellular  struc- 
tures present. 

We  have  also  seen  that  in  different  examinations  of  lice  fed 
only  upon  healthy  individuals,  the  Rickettsia  have  been  dem- 
onstrated in  from  20  to  74  per  cent  of  them.  Knowing  these 
facts  let  us  suppose  that  lice  already  containing  such  sapro- 
phytic Rickettsia  in  variable  number  had  been  fed  upon  trench 
fever  cases  and  had  become  infected  with  the  virus  of  trench 
fever,  and  such  lice  (containing  the  Rickettsia  which  may  in  the 
meantime  have  multiplied  or  increased  in  number)  were  then 
placed  upon  healthy  human  beings  whom  they  subsequently 
infected  with  trench  fever,  obviously  then  erroneous  con- 
clusions might  be  drawn  that  the  Rickettsia  were  themselves 
the  aetiological  factor  of  trench  fever.  It  is  evident  that  great 
difficulty  would  be  experienced  in  a  separation  of  the  virus  of 
trench  fever  from  such  bodies  under  the  circumstances  de- 
scribed  above.     Probably  only  by  successful  filtration  ex- 

1  Trench  Fever:  Report  of  Commission  of  American  Red  Cross  Research  Committee, 
Oxford  University  Press,  1918. 

2  Bradford,  Bashford,  and  Wilson:  Brit.  Med.  Jour.,  1919,  i,  127. 
^  Loc.  cit. :  Trench  Fever  Report,  p.  27. 


84  TYPHUS  FEVER 

periments,  such  as  we  have  performed  with  lice  excrement 
in  connection  with  trench  fever,  could  the  separation  be 
accomplished. 

It  of  course  may  be  argued  that  Rickettsia  have  a  filter- 
able stage  as  have  other  so-called  chlamydozoa,  and  this  idea 
receives  some  support  from  the  fact  that  the  virus  of  trench 
fever  is  under  some  circumstances  filterable  with  difficulty,  and 
attempts  to  infect  human  beings  with  the  filtrates  of  infected 
material  are  often  unsuccessful.  Thus  in  ten  filtration  exper- 
iments performed  with  infected  blood  and  urine  from  trench 
fever  cases,  and  infected  louse  excrement,  only  three  with  urine 
gave  undoubted  positive  results.  The  temperature  charts  of 
two  cases  of  trench  fever  experimentally  produced  by  the  in- 
jection of  the  filtered  trench  fever  virus  are  illustrated  in 
Plate  XXII. 

Bradford,  Bashford,  and  Wilson  ^  have  since  reported  upon 
the  cultivation  of  the  trench  fever  virus  from  filtrates  which 
have  previously  passed  through  porcelain  filters  and  have  also 
shown  by  human  experiments  that  such  filtrates  contain  the 
infectious  agent. 

It  is  conceivable  that  the  Rickettsia,  whether  they  possess  a 
filterable  stage  or  not,  may  be  parasites  of  lice  and  not  path- 
ogenic for  man,  and  Brumpt  has  suggested  that  the  finding  of 
them  in  human  blood  may  simply  be  an  indication  that  the 
individual  has  been  previously  infested  with  lice.  On  the  other 
hand,  there  is  the  possibility  that  the  bodies  sometimes  de- 
scribed as  Rickettsia  may  constitute  products  of  degenerated 
cells,  for  example,  basophilic  granules,  which  are  more  numer- 
ous in  the  blood  in  certain  febrile  diseases,  in  which  case  they 
would  also  increase  in  number  in  the  lice  fed  upon  such  cases, 
and  might  then  merely  accompany  the  very  minute  or  invisible 
aetiological  factor  of  the  disease.  Finally,  there  may  be  at 
least  three  distinct  species  of  Rickettsia,  —  R.  prowazeki,  R. 
Volhynia,  and  the  third  form  either  intra  or  extracellular, 
found  in  lice,  and  non-pathogenic  for  man.^ 

1  Bradford,  Bashford,  and  Wilson:  loc.  cit. 

2  Rocha-Lima:  Deutsch.  med.  Wchnschr.,  1919,  p.  732. 


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{Reprinted  with  permission  of  Paul  B.  Hoeber,  Publisher  of  Osier  Anniversary  Volume) 

PLATE  XXII 


THE  SERBIAN  EPIDEMIC  85 

In  connection  with  the  significance  of  Rickettsia  as  an 
aetiological  factor  in  typhus,  trench  fever,  and  other  diseases, 
it  may  be  of  interest  to  recall  that  in  1903  an  organism  de- 
scribed by  Parker,  Beyer,  and  Pothier  as  Myxococcidium 
stegomyiae  was  found  in  infected  stegomyia  mosquitoes,  and 
was  for  a  time  supposed  by  these  investigators  to  be  the 
parasite  causing  yellow  fever.  Later  this  organism  was  found 
to  be  a  species  of  yeast,  and  to  occur  not  only  in  mosquitoes  in- 
fected with  the  virus  of  yellow  fever,  but  also  in  those  not  in- 
fected with  such  virus,  and  the  virus  of  yellow  fever  was  shown 
to  be  filterable  and  supposedly  ultramicroscopic.^ 

From  a  review  of  the  evidence  presented  in  this  paper  re- 
garding Rickettsia,  it  appeared  obvious  that  until  more  definite 
results  were  obtained  from  further  experimental  work  that  we 
were  not  justified  in  finally  concluding  that  the  Rickettsia  have 
a  definite  specific  aetiological  significance  in  relation  to  typhus 
fever,  even  though  there  was  much  evidence  in  favor  of  this 
idea.  Hence  it  seemed  advisable  for  the  Medical  Department 
of  the  League  of  Red  Cross  Societies  to  appoint  a  special  Com- 
mission to  study  anew  the  question  of  the  aetiology  of  this 
disease.  This  Commission,  consisting  of  Dr.  S.  B.  Wolbach  of 
Harvard  University,  chairman,  and  a  staff  of  seven  members 
including  Dr.  John  L.  Todd,  associate  professor  of  parasitology 
at  McGill  University,  Dr.  A.  Bacot,  entomologist  of  the  Lister 
Institute,  London,  and  Dr.  Frank  W.  Palfrey,  instructor  in 
medicine  at  Harvard  University,  have  now  nearly  completed 
their  investigations  upon  the  aetiology  of  this  disease  and  their 
full  report  upon  this  subject  will  shortly  be  published.^  Their 
very  painstaking  and  careful  studies  seem  to  show  that  typhus 
fever  is  caused  by  the  Rickettsia  prowazeki  of  Rocha-Lima. 

However,  while  there  has  been  much  difference  of  opinion  ^ 
regarding  the  specific  organism  of  typhus  fever,  as  we  are 
famihar  with  the  method  of  transmission  of  the  disease,  the 

1  Noguchi's  recent  experiments,  however,  point  to  the  fact  that  the  organism  of  yel- 
low fever  is  a  spirochaete.  This  according  to  other  experiments  is  filterable  at  least  at 
one  stage  of  its  life  history.    (Jour.  Am.  Med.  Assn.,  1919,  Ixxii,  187.) 

2  Wolbach,  Todd,  and  Palfrey:  Intern.  Jour.  Pub.  Health,  Geneva,  1920,  ii,  211. 

3  NicoUe:  Bull,  de  I'Inst.  Pasteur,  1920,  xviii,  1. 


86  TYPHUS  FEVER 

exact  nature  of  the  aetiological  factor  in  connection  with  the 
control  of  epidemics  is  of  importance  particularly  in  connection 
with  the  hope  that  when  the  organism  causing  the  disease  has 
been  definitely  isolated  and  cultivated,  a  satisfactory  form  of 
protective  inoculation  or  a  satisfactory  method  of  serum- 
therapy  will  be  developed. 

Weil-Felix  Reaction 

The  Weil-Felix  reaction  (agglutination  or  clumping  of  Bacil- 
lus proteus  X  19  obtained  from  the  urine  of  cases  of  typhus  by 
the  serum  of  typhus  fever  cases  in  dilutions  of  1-100  to  1-2000 
or  higher)  was  not  described  by  Weil  and  Felix  until  1916, 
although  Wilson  ^  had  isolated  in  1910  from  the  faeces  of  one 
case  and  from  the  urine  of  two  cases  a  variant  form  of  B.  coli 
communis  which  was  agglutinated  by  the  serum  of  seventeen 
cases  of  typhus  and  not  by  normal  serum.  Very  extensive  ex- 
periments performed  since  1916  have  demonstrated  that  the 
Weil-Felix  reaction  occurs  in  from  90-100  per  cent  of  typhus 
cases,  and  sometimes  in  dilutions  of  the  serum  as  high  as 
1-30,000,  about  50  per  cent  of  the  cases  giving  the  reaction  by 
the  fifth  day  and  practically  all  by  the  tenth  day  of  the  disease. 
Even  though  it  is  the  consensus  of  opinion  that  the  reaction  is 
not  specific,  and  that  Bacillus  proteus  X 19  cannot  be  identified 
as  the  cause  of  the  disease,  its  value  as  a  method  of  diagnosis 
of  typhus  is  generally  acknowledged.  However,  the  value  of 
the  reaction  as  a  means  of  diagnosis  in  typhus  fever  had  not 
been  emphasized  in  1915,  and  the  reaction  was  not  employed 
in  Serbia  in  our  laboratories  for  the  diagnosis  of  the  disease. 
During  the  severe  period  of  the  epidemic,  the  admissions  into 
the  hospitals  were  so  high  as  to  have  precluded  the  use  of  any 
such  method,  the  diagnosis  from  the  clinical  manifestations  of 
the  disease  being  the  only  method  at  all  practical  under  the 
circumstances  already  described. 

Bacteriological  Studies  in  Serbia 

The  bacteriological  studies  that  were  carried  on  in  Serbia 
during  the  epidemic  did  not  confirm  the  fact  that  any  one  of 

1  Wilson:  Jour.  Hyg.,  Lond.,  1910,  x,  155. 


THE  SERBIAN  EPIDEMIC  87 

the  bacteria  previously  described  as  specific  was  in  fact  the 
aetiological  factor  in  the  disease.  The  investigations  carried  on 
by  Zinsser,  Sellards,  and  Hopkins,  of  the  American  Red  Cross 
Sanitary  Commission,  did  not  confirm  the  fact  that  the  Bacil- 
lus typhi  exanthematici  described  by  Plotz  was  the  aetiological 
factor,  and  no  other  organism  was  isolated  which  was  regarded 
as  specific.  These  investigations  are  referred  to  in  greater  detail 
later  in  this  Report.^ 

Reference  has  also  been  made  to  the  work  of  Topley  who 
also  failed  during  the  Serbian  epidemic  to  isolate  the  Bacil- 
lus typhi  exanthematici  of  Plotz,  though  it  was  sought  for. 
Topley,  however,  reported  the  finding  of  a  diplococcus  which 
he  regarded  as  specific,  but  this  isolation  was  not  confirmed  by 
other  investigators. 

Penfold,  1916,^  was  also  not  able  to  isolate  the  Bacillus  typhi 
exanthematici  though  he  too  isolated  a  coccus  from  four  cases 
of  the  disease.  Muriel  Robertson^  was  unable  to  immunize 
monkeys  against  typhus  infection  with  this  coccus.  On  the 
other  hand,  Plotz 's  colleagues,  Olitsky,  Denzer,  and  Husk,* 
and  Baehr,^  Paneth,®  and  Popoff,^  have  all  reported  the  isola- 
tion of  this  organism  from  cases  of  typhus.  With  so  many 
contradictory  reports,  and  particularly  when  one  compares  the 
results  of  Plotz  and  his  colleagues  with  those  obtained  by 
Rocha-Lima,  Toepfer,  Schuessler,  Noeller,  Wolbach,  Todd,  and 
others  in  relation  to  Rickettsia,  it  seems  obvious  at  least  that 
further  experimental  work,  will  be  necessary  before  unanimity 
of  opinion  is  secured. 

Course  of  Serbian  Epidemic 

As  has  been  stated,  the  epidemic  increased  steadily  through 
January,  February,  March,  and  April,  reaching  its  height  for 
all  of  Serbia  in  April.    By  this  time  almost  one  in  five  of  the 

^  Wolbach,  Todd,  and  Palfrey  also  failed  to  isolate  this  organism  in  their  recent  work 
in  Poland. 

^  Penfold:  loc.  cit.  ^  Robertson:  Jour.  Path,  and  Baeteriol.,  1917,  xxi,  173. 

*  Olitsky,  Denzer,  and  Husk:  Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  1692. 

5  Baehr:  Jour.  Infect.  Dis.,  1917,  xx,  201. 

6  Paneth:  Med.  Klin.,  1916,  p.  647,  and  Arch.  f.  Hyg.,  1916,  Ixxxvi,  63. 

7  Popoff:  Deutsch.  Med.  Wchnschr.,  1916,  xlii,  471. 


88  TYPHUS  FEVER 

Serbian  people  had  contracted  the  disease.^  Toward  the  end  of 
April,  however,  the  effort  throughout  the  country  to  overcome 
the  spread  of  the  disease  had  generally  become  determined  and 
united.  The  greatest  credit  is  due  to  the  Serbian  medical 
officers  and  other  officials  and  to  the  Serbian  people  themselves, 
for  the  heroic  and  determined  manner  in  which  in  the  midst  of 
their  sufferings  this  anti-typhus  campaign  once  organized  was 
pursued  by  them,  practically  all  attention  and  effort  in  Serbia 
being  centered  upon  the  extermination  of  the  disease. 

At  this  period  there  were  engaged  in  combating  the  epidemic 
in  addition  to  the  Serbian  sanitarians,  doctors,  and  other 
officials,  detachments  of  physicians,  sanitarians,  and  nurses 
from  France,  Great  Britain,  Russia,  Belgium,  Holland,  and  the 
United  States. 

The  foreign  personnel  consisted  particularly  of  Colonel 
Jaubert  with  100  French  physicians  and  sanitarians;  Sir  Ralph 
Paget  with  a  number  of  hospital  units  from  Great  Britain  under 
the  individual  direction  of  Lady  Paget  (with  Dr.  Maitland 
as  chief  physician),  Dr.  Elsie  Inglis,  Dr.  Alice  Hutchinson  of 
the  Scottish  Women  Hospitals,  Mrs.  Stobart,  Dr.  Barrie,  Dr. 
Berry,  and  Captain  Bennet,  also  a  military  sanitary  mission 
under  Colonel  Hunter  with  whom  were  Major  Stammers  and 
Captain  Topley  with  twenty-one  lieutenants;  a  contingent  of 
Russian,  Belgian,  and  a  few  Dutch  physicians  employed  in 
connection  with  the  Serbian  army;  the  American  Red  Cross 
hospital  units  under  the  general  direction  of  Dr.  Edward  Ryan 
at  Belgrade;  the  American  Red  Cross  hospital  units  of  Dr. 
Ernest  Magruder  and  Dr.  James  Donnelly  (both  of  whom  gave 
up  their  lives  during  the  epidemic),  of  Dr.  Ethan  Flagg  Butler 

1  It  has  been  suggested  that  the  reduction  of  passenger  travel  from  two  trains  to  one 
on  one  of  the  railways  extending  from  the  north  through  Kraguevatz  on  March  16  had  a 
decided  effect  upon  the  admission  of  typhus  cases  to  the  hospitals  in  this  district.  This 
is  undoubtedly  true  since  fewer  patients  were  brought  or  came  by  train  to  these  hospitals 
during  this  period.  On  resumption  of  travel,  however,  more  cases  were  again  sent  to  these 
hospitals  and  their  records  began  to  show  an  increased  admission  of  typhus  cases.  During 
the  period  of  partially  interrupted  train  service  many  of  the  typhus  cases  were  evacuated 
by  ambulances  to  other  hospitals  in  central  and  southern  Serbia.  It  should  be  noted  that 
by  March  16  typhus  was  widely  disseminated  throughout  Serbia  and  hence  measures 
taken  locally  obviously  could  not  and  did  not  materially  affect  the  course  of  the  disease 
throughout  the  country,  and  particularly  its  course  in  the  civil  population. 


THE  SERBIAN  EPIDEMIC  89 

and  Dr.  Kirby-Smith ;  as  well  as  a  number  of  American  phy- 
sicians assigned  to  the  Serbian  army  in  addition  to  the  sanitary 
commission  of  the  American  Red  Cross,  numbering  in  all  ap- 
proximately 100  physicians.  Of  the  American  Sanitary  Com- 
mission, Dr.  Thomas  W.  Jackson  was  chief  sanitary  inspector; 
Dr.  Hans  Zinsser,  bacteriologist;  Dr.  Aldo  Castellani,  con- 
sultant in  tropical  medicine  and  bacteriology;  Dr.  George  C. 
Shattuck,  clinician;  Dr.  A.  Watson  Sellards,  chief  of  clinical 
laboratory;  Dr.  B.  W.  Caldwell,  hospital  administrator;  Dr. 
F.  B.  Grinnell,  sanitary  inspector;  Mr.  Edward  Stuart,  sani- 
tary engineer;  Dr.  Hopkins,  assistant  bacteriologist;  and  Mr. 
Arthur  S.  Ward,  secretary. 

I  wish  particularly  to  emphasize  that  it  was  the  combined 
efforts  of  the  Serbian  medical  and  sanitary  officers  and  other 
officials  and  of  the  Serbian  people  themselves,  together  with 
those  of  the  personnel  of  the  foreign  detachments  referred 
to,  which  soon  began  to  show  definite  effects  upon  the 
course  of  the  epidemic  and  from  the  beginning  of  May  until 
August,  when  the  epidemic  was  at  an  end,  the  decline  of  fever 
cases,  not  in  any  one  locality  alone  but  throughout  the  coun- 
try, was  continual.  The  accompanying  chart  which  shows  the 
curve  of  fever  cases,  typhus,  relapsing,  and  typhoid,  in  the 
civilian  population  throughout  the  country  for  this  period, 
strikingly  illustrates  this  fact.  Undoubtedly  the  approach  of 
warm  weather  aided  not  only  the  officials  concerned,  but  the 
people  themselves  in  the  success  of  the  campaign,  but  no  one 
who  was  concerned  with  this  campaign  can  doubt  the  efficacy 
of  sanitary  measures  in  connection  with  the  prevention  of  the 
spread  of  typhus  fever.  If  no  such  anti-typhus  campaign  had 
been  carried  out,  it  is  extremely  probable  that  the  disease  would 
have  diminished  during  the  summer  months  only  to  reappear 
with  greater  intensity  during  the  following  winter,  which  is 
what  has  happened  in  Poland.^ 

^  Typhus  appeared  in  Poland  in  epidemic  form  particularly  in  1916.  Satisfactory 
preventive  measures  were  not  carried  out,  and  the  hope  was  expressed  that  the  disease 
would  disappear  during  the  summer.  However,  the  arrival  of  summer  seemed  to  have 
little  or  no  effect  in  stopping  the  epidemic,  though  the  number  of  cases  was  somewhat 
decreased  during  the  summer  months.  Each  summer  the  same  hope  has  been  expressed, 
the  epidemic  continues  to  rage,  now  in  its  fourth  year. 


90  TYPHUS  FEVER 

# 

The  work  of  these  various  foreign  units  in  Serbia  referred  to 
above  has  been  reported  upon  in  various  pubhcations  made  by 
their  respective  directors  and  hence  will  not  further  be  alluded 
to  here. 

Acknowledgments 

It  is  perhaps  proper,  however,  in  this  report  of  the  American 
Red  Cross  to  say  something  regarding  the  American  Sanitary 
Commission,  and  to  quote  from  a  preliminary  report  ^  made  to 
the  American  Red  Cross  in  1915  upon  this  subject  and  not 
widely  circulated.  "  The  American  Red  Cross  and  Rockefeller 
Foundation  have  supported  the  American  Red  Cross  Sanitary 
Commission  in  every  way  and  have  supplied  it  with  all  the  nec- 
essary equipment  and  personnel.  Every  request  which  I  made 
was  granted.  I  cannot  speak  too  highly  of  the  personnel  of 
the  Commission,  and  I  do  not  believe  that  a  finer  and  more 
competent  group  of  sanitarians  and  physicians  were  ever  got- 
ten together.  Much  of  the  success  of  the  work  in  Serbia  was 
due  to  their  efforts. 

'^In  this  brief  statement  it  is  impossible  to  do  justice  to  all, 
but  the  names  of  Dr.  Thomas  W.  Jackson,  chief  sanitary  in- 
spector, whom  I  left  in  charge  after  my  departure;  Dr.  Hans 
Zinsser,  bacteriologist;  Dr.  Francis  B.  Grinnell,  sanitary  in- 
spector; Dr.  George  C.  Shattuck,  clinician;  Dr.  A.  Watson 
Sellards,  who  had  charge  of  the  chnical  laboratory  work;  Dr. 
B.  W.  Caldwell,  hospital  administrator,  and  Dr.  Aldo  Castel- 
lani,  consultant  in  tropical  medicine  and  bacteriology,  are 
deserving  of  the  highest  mention.  All  of  these  gentlemen  with 
the  exception  of  Dr.  Castellani,  who  joined  shortly  afterwards, 
went  to  Serbia  as  members  of  the  first  commission.  The  name 
of  Mr.  Edward  Stuart,  the  sanitary  engineer  of  the  Commission, 
also  calls  for  special  mention.  His  advice  and  work  in  connec- 
tion with  the  many  important  sanitary  problems  in  Serbia  have 
been  invaluable. 

"Among  the  second  group  of  men  attached  to  the  Commis- 
sion, Colonel  Gale,  Doctors  Mendelssohn  and  Gruver,  Mr. 
Brink  and  others,  and  among  the  still  later  arrivals  Dr.  Harry 

1  American  Red  Cross  Magazine,  1915,  x,  346. 


Chart  showing  decrease  in  fever  cases,  typhus,  relapsing,  and  typhoid 

AMONG   THE   CIVILIAN   POPULATION,    MaY   TO    AuGUST,  1915 


PLATE  XXIII 


THE  SERBIAN  EPIDEMIC  91 

Forbes  and  Dr.  J.  G.  Hopkins,  all  held  responsible  positions  in 
the  Serbian  work." 

Mr.  Arthur  S.  Ward  acted  as  secretary  during  the  most  try- 
ing periods  of  the  epidemic,  and  Mr.  Charles  R.  Cross,  who 
afterwards  died  while  performing  other  war  service  in  France, 
was  disbursing  officer  of  the  Commission,  while  Mr.  D.  B. 
Tripcevich  and  Mr.  Ranko  Jovanovich  acted  as  interpreters 
and  translators,  particularly  in  connection  with  official  records.^ 

At  the  time  of  the  organization  in  1915  of  the  Commission, 
''Major  General  Gorgas,  Surgeon  General  of  the  United  States 
Army,  most  generously  gave  me  his  advice  in  relation  to  the 
equipment  and  personnel  of  this  Commission,  and  I  am  glad  to 
have  this  opportunity  of  expressing  again  my  gratitude  for  this 
most  valuable  assistance.  Later  he  generously  offered  to  give 
up  his  position  as  head  of  the  Medical  Corps  of  the  United 
States  Army,  if  necessary,  and  come  to  Serbia  if  the  epidemic 
could  not  be  controlled.  Fortunately  for  the  army  this  sacri- 
fice on  his  part  did  not  become  necessary. 

"  Surgeon  General  Rupert  Blue,  United  States  Pubhc  Health 
Service,  and  Colonel  Fisher,  Medical  Corps,  United  States 
Army,  have  also  made  valuable  recommendations,  and  Miss 
Boardman  was  untiring  in  her  efforts  of  organization. 

''Yale  University,  particularly  through  the  offices  of  Pro- 
fessor Beebe,  Madame  Slavko  Grouitch  and  others,  and  Har- 
vard University,  particularly  through  Dr.  F.  C.  Shattuck  and 
others,  sent  special  funds  for  the  work  and  Mrs.  William  H. 
Forbes,  of  Boston;  Mrs.  McMullen,  of  New  Rochelle,  and  Mr. 
W.  H.  Converse  have  also  generously  given  me  financial  assist- 
ance for  relief  work  in  Serbia. 

"Through  the  International  Sanitary  Commission  at  Nish, 
the  most  complete  and  cordial  cooperation  was  secured  between 
the  French,  British,  Russian,  and  American  and  other  phy- 
sicians and  sanitarians  working  in  Serbia.  I  cannot  speak  too 
highly  of  the  work  of  many  of  my  foreign  colleagues.  Among 
the  British  relief  workers  in  Serbia  the  work  of  Lady  Paget 
and  of  her  husband.  Sir  Ralph,  and  of  Sir  Thomas  Lipton,  must 
be  specifically  mentioned.     Lady  Paget's  hospital,  which  she 


92  TYPHUS  FEVER 

directed  herself  until  she  became  a  victim  of  typhus,  and  of 
which  she  again  assumed  the  directorship  as  soon  as  she  was 
convalescent,  is  equipped  with  over  five  hundred  beds  and  has 
done  most  admirable  work.  It  is  only  equalled  in  efficiency 
by  one  other  hospital  in  Serbia.  Sir  Ralph  Paget  has  worked 
untiringly  and  faithfully  in  the  discharge  of  his  duties,  as  has 
his  wife.  Sir  Thomas  Lipton,^  apart  from  the  financial  support 
he  has  given  and  secured  for  Serbia,  has  encouraged  and  sup- 
ported the  medical  and  sanitary  work  in  Serbia  in  many  ways 
and  has  rendered  innumerable  kindnesses  and  supplied  count- 
less comforts  for  Red  Cross  workers  in  Serbia." 

''The  best  equipped  and  managed  hospital  in  Serbia  is  the 
American  Hospital  in  Belgrade,  of  which  Dr.  Ryan  is  the  direc- 
tor and  Miss  Gladwin  the  chief  nurse.  Here  patients  receive 
the  same  efficient  care  and  comfort  which  they  do  in  many  of 
our  best  hospitals  in  the  United  States.  Dr.  Ryan,  during  the 
height  of  the  epidemic,  worn  out  with  overwork,  was  stricken 
with  typhus.  He  kept  at  work,  however,  until  he  became 
delirious,  when  he  was  taken  charge  of  and  treated  by  Dr. 
Kirby-Smith.  As  soon  as  his  fever  subsided,  he  resumed 
charge  of  his  hospital.  I  could  not  do  justice  to  the  great  work 
Dr.  Ryan  ^  has  done  in  Serbia  in  a  few  words,  and  Miss  Glad- 
win's work  also  merits  the  highest  praise. 

"Colonel  Hunter  and  Major  Stammers  of  the  British  Sani- 
tary Unit  also  were  of  much  assistance  in  the  suppression  of 
the  epidemic,  the  former  being  in  charge  of  the  sanitary  work 
of  the  army  about  Kraguevatz  and  the  latter  in  charge  of  one  of 
the  sanitary  vaccinating  trains  and  other  sanitary  work  for  a 
part  of  the  time.  These  gentlemen  unfortunately  were  recalled 
to  render  aid  to  the  British  wounded  in  the  Dardanelles.  The 
French  physicians,  under  the  able  leadership  of  Colonel  Jau- 
bert,  and  the  Russian  staff,  under  Colonel  Solfatero,  also  rend- 
ered most  important  assistance. 

^  Sir  Thomas  Lipton  on  voyages  with  the  Erin  brought  numerous  physicians  and 
nurses,  and  sixty  tons  of  medicines  and  hospital  comforts. 

2  Dr.  Ryan  and  his  assistant  surgeons  were  in  Belgrade  during  all  of  its  bombard- 
ments and  surrenders. 


.^-^ 

v^ 

At- 

■^ 

^    ^1,,. 

jfll*^n 

■s^P*^^^^'    -^^^^^^^^M    ^M 

MB         ^^  *      * 

1 

^W^ 

"^i^^^^^l 

•^^^^.^  ^^^VII^Hh 

SiE  Thomas  Lipton  on  board  the  "Erin' 


PLATE  XXIV 


Dr.  Edward  Ryan  convalescing  from  typhus  fever  and 
Miss  Gladwin,  chief  nurse,  A.  R.  C. 


PLATE  XXV 


THE  SERBIAN  EPIDEMIC  93 

''Assistance  that  was  particularly  welcome  was  given  by  the 
American  Relief  Clearing  House  in  Paris,  especially  through 
Messrs.  Scott,  Hargis,  and  Carter." 

I  wish  to  particularly  express  my  appreciation  to  Miss 
Catherine  M.  Casassa,  Secretary  of  the  School  of  Tropical 
Medicine  at  Harvard  University  Medical  School,  for  much 
Valuable  assistance  in  connection  with  the  preparation  of  this 
entire  Report,  and  for  having  read  the  proof  of  the  same. 

End  of  Epidemic 

Writing  in  1915  I  expressed  the  opinion  that  the  sanitary 
demonstrations  and  instruction  in  the  prevention  of  typhus 
fever  which  had  been  given  to  the  Serbian  people,  and  the  con- 
struction and  use  of  the  various  permanent  disinfesting  plants 
which  had  been  established  through  the  country,  would  pre- 
vent the  occurrence  of  another  epidemic  of  such  severity  as  to 
destroy  in  the  neighborhood  of  150,000  people.^ 

This  opinion  seems  to  have  been  justified  and  there  has  been 
no  epidemic  of  this  disease  in  Serbia  of  any  magnitude  since 
this  time.  However,  tjrphus  fever  is  and  has  been  endemic  in 
the  Balkans  for  many  years  and  a  few  cases  of  it  still  occur  and 
others  are  introduced  into  Serbia  from  time  to  time.^ 

The  Polish  Epidemic  of  Typhus,  1916  ..  . 

On  account  of  the  assistance  which  the  American  Red  Cross 
and  other  national  Red  Cross  societies  under  the  coordination 
of  the  League  of  Red  Cross  Societies  are  extending  to  Poland 
in  connection  with  the  typhus  epidemic  now  raging  in  that 
country,  it  also  seems  advisable  to  review  in  this  report  the 
existing  conditions  in  Poland,  and  the  steps  already  taken  in 
connection  with  this  epidemic. 

1  The  official  record  of  the  Secretary  of  War  at  Serbia  gives  the  number  of  deaths 
from  all  cases  for  the  army  in  1915  as  171,725. 

2  Typhus  fever  was  reported  prevalent  in  Macedonia  in  1919,  the  disease  being  trace- 
able to  refugees  returning  from  Bulgaria,  especially  from  Varna,  and  other  Black  Sea 
ports.  A  number  of  cases  were  reported  present  at  Drama,  but  without  spread  of  the 
disease.  At  Kavala  about  300  cases  were  officially  reported;  the  outbreak  was  success- 
fully dealt  with  locally  by  Dr.  Samuel  J.  Walker  of  the  American  Red  Cross. 


94  TYPHUS  FEVER 

Russia  as  an  Endemic  Center  of  Typhus 

Poland  was  formerly  recognized  as  an  endemic  area  of  tj^hus 
and  Russia  itself  has  been  regarded  as  one  of  the  great  endemic 
centers  of  typhus  in  Europe.  Epidemics  in  Poland  have  oc- 
curred in  the  nineteenth  century  particularly  in  1830-31,  when 
the  disease  was  introduced  by  troops,  and  in  1842-46  when 
there  was  a  general  epidemic  throughout  Poland.  In  Galicia 
where  the  disease  is  also  regarded  as  endemic,  we  know  that 
typhus  was  general  in  1846-47;  but  complete  statistics  from 
these  countries  have  not  been  available.  However,  for  the  ten 
years  preceding  1916,  in  the  whole  of  Russian  Poland,  with  a 
population  of  about  thirteen  million,  the  average  number  of  re- 
ported tjrphus  fever  cases  was  less  than  2000  annually.^  In  all 
Congress  Poland,  before  the  war  it  has  been  estimated  by  the 
Polish  Ministry  of  Health  that  there  were  in  the  neighborhood 
of  6000  cases  annually.  Low,  1916,^  gives  as  the  number  of 
deaths  from  typhus  fever  for  Galicia  from  1895-1904  (ten 
years)  5592;  and  for  1905-12  (8  years  only),  2181;  while  for 
Poland  from  1905-11  (7  years),  1126. 

The  Present  Polish  Epidemic 

Towards  the  latter  part  of  1916  typhus  became  epidemic  in 
Poland,  the  chief  area  at  first  affected  being  the  governmental 
district  of  Warsaw.  This  district  at  the  time  was  occupied  by 
German  troops,  and  was  then  being  administered  as  German 
territory.  From  the  returns  published  by  the  Central  Imperial 
Health  Department  in  Berlin,  it  appeared  that  26,099  cases 
were  reported  in  about  twelve  months  in  the  government  dis- 
trict of  Warsaw  which  had  a  population  of  only  two  and  one-half 
million,  853,000  of  which  resided  in  the  city  of  Warsaw.  In 
Congress  Poland  and  Galicia  combined,  the  cases  reported  for 
1916  were  34,538.  The  measures  taken  against  the  epidemic  in 
1916  and  in  1917  failed  to  check  its  spread,  but  the  hope  was 
expressed  that  the  epidemic  would  disappear  in  the  summer 
months.    The  summer  of  1917  however  seemed  to  have  little 

1  Lancet,  London,  1918,  i,  150. 

2  Low:  Eleventh  Annual  Report,  Local  Government  Board,  1914-15. 


THE  SERBIAN  EPIDEMIC  95 

effect  in  reducing  the  number  of  cases  of  the  disease,  and  for  the 
year  1917  the  cases  for  the  same  territory  numbered  43,840. 
The  epidemic  was  again  not  suspended  the  next  year  by  the 
summer  months,  and  in  1918  the  number  of  cases  more  than 
doubled  those  in  1917,  amounting  to  97,082.  Since  December, 
1918,  Poland  as  an  independent  state  has  had  control  over  this 
territory  and  the  Polish  government  has  carried  on  measures 
against  the  epidemic.  During  the  first  year  of  the  existence  of 
the  Polish  Public  Health  Service  the  number  of  cases  of  typhus 
reported  to  the  Ministry  of  Public  Health  was  as  follows : 

Cases  Deaths  Per  cent 

Congress  Poland 161,042  12,632  7.8 

GaUcia 70,158  7,250  10.3 

Poznania 106 9  8.5 

Total 231,306  19,891  8.6 

During  the  months  of  January  and  February  of  1920  the 
number  of  cases  notified  was  as  follows: 

Congress  Poland 12,098 

Galicia 34,476 

During  the  spring  and  summer  of  1919  the  disease  showed  a 
considerable  decrease  in  certain  portions  of  Congress  Poland, 
but  the  number  of  cases  again  rose  in  November,  and  this 
number  has  remained  practically  stationary.  Nevertheless  it 
about  equals  the  number  of  cases  that  were  present  during 
January  and  February  a  year  ago  (1919).  In  Galicia,  however, 
the  disease  has  not  even  remained  stationary.  There  was  a  dis- 
tinct rise  in  December,  1919,  which  has  continued  through 
January  and  February  of  1920.  These  figures  speak  for  them- 
selves. They  show  that  the  epidemic  is  now  well  into  its  fourth 
year  and  they  demonstrate  that  the  measures  which  have  been 
employed  by  the  Polish  government  to  combat  the  epidemic 
have  not  yet  been  as  successful  and  as  effective  as  was  hoped. 
Colonel  H.  L.  Gilchrist  of  the  United  States  Army  Medical 
Corps,  attached  to  the  Polish  Ministry  of  Health,  and  fighting 
typhus  fever  in  "Poland,  in  a  report  written  in  March,  1920, 
says  ''the  typhus  epidemic  which  for  the  fourth  year  in  suc- 
cession has  been  raging  in  Poland,  has  increased  in  intensity 


96  TYPHUS  FEVER 

each  year,  due  probably  to  the  large  influx  of  refugees  and 
prisoners  of  war  from  Russia,  and  to  the  thousands  of  cases 
being  imported  from  the  interior  of  Ukrania  and  other  eastern 
territories.  The  situation  at  present  is  getting  beyond  control." 
In  describing  the  conditions  in  parts  of  Galicia,  he  writes : 
"  In  Galicia  whole  towns  are  crippled.  Schools  are  closed  and 
business  practically  suspended  from  the  effects  of  the  disease. 
In  the  northeast  of  Poland,  American  inspectors  report  the 
disease  raging  as  affecting  nearly  every  home,  with  a  high 
mortality.    Starvation  and  lack  of  clothing  and  medicines  are 
also  in  evidence.    There  are  few  doctors  and  no  nurses.    As  a 
result  of  the  ravages  of  the  past  war,  and  the  fact  that  Poland 
has  been  occupied  by  several  armies  which,  when  retreating, 
either  destroyed  or  took  with  them  all  the  materials  of  any 
value,  the  eastern  country  has  been  left  with  only  absolutely 
meager  essentials.    Homes  which  for  the  most  part  are  only 
rudely  constructed  affairs,  and  without  furniture  of  any  kind, 
offer  shelter  for  thousands  of  these  sufferers.    They  have  no 
beds  and  lie  on  straw  or  hay-strewn  floors.   The  same  materials 
answer  the  purpose  of  protecting  them  against  the  Polish  win- 
ters.   Many  of  these  small  huts  consist  of  but  a  single  room, 
and  here  father,  mother,  and  several  children  reside.    The  pres- 
ent article  of  diet  in  the  majority  of  cases  consists  of  potatoes, 
beets  or  other  vegetables,  and  these  in  only  starvation  quanti- 
ties.   They  seldom  see  bread.    Meat  is  furnished  only  occa- 
sionally.   At  present  nearly  every  house  has  from  one  to  five 
cases  of  typhus  fever,  all  lying  on  the  usual  beds  of  straw  or 
hay.    Houses  have  been  visited  by  me  in  which  the  entire 
families  were  stricken,  some  delirious,  and  without  medical 
attention  of  any  kind.  Some  cases  were  found  in  which  the  only 
nourishment  consisted  of  raw  potatoes  or  raw  beets.     The 
friendly  natives  are  doing  what  they  can  to  reUeve  this  suffer- 
ing, but  due  to  the  shortage  of  the  essentials  of  Hf  e  their  aid  is  of 
little  avail.    Doctors  and  nurses  are  unknown  to  these  people, 
the  peasants  acting  as  combined  doctors,  nurses,  and  under- 
takers.  If  the  dead  have  no  near  relatives  to  claim  their  effects, 
the  bodies  are  stripped  before  burial  and  their  clothing  taken 


THE  SERBIAN  EPIDEMIC  97 

away  in  ignorance  by  the  peasants  to  distant  parts  to  be  sold, 
thus  implanting  the  disease  in  new  areas." 

The  circumstances  which  have  been  given  by  the  Polish  Min- 
ister of  Health  as  responsible  for  the  spread  of  the  epidemic  are : 

1.  The  war  devastation  of  Congress  Poland  and  Galicia  and 
its  consequences. 

2.  The  administrative  chaos  which  followed  the  sudden 
withdrawal  of  the  authorities  occupying  the  Polish  territories, 
and  the  disorderly  demobilization  as  well  as  the  reemigration 
and  the  return  movement  of  war  prisoners  from  the  East. 

3.  Great  scarcity  of  sanitary  materials  and  of  professional 
personnel. 

4.  The  absence  of  every  kind  of  sanitary  service  in  the  east- 
ern territories  at  the  time  of  their  occupation  by  the  Polish 
troops. 

5.  The  breaking  up  of  the  various  Russian  and  Ukranian 
armies  of  Deniken,  Petlura,  Bredow,  and  the  admission  of  these 
returning  troops  which  the  Polish  government  felt  compelled 
to  receive  into  their  lines. 

6.  The  impossibility  of  maintaining  a  rigid  sanitary  cordon 
on  the  eastern  confines  of  the  Polish  civilian  and  military  ad- 
ministration, owing  to  the  lack  of  essential  supplies  and  scar- 
city of  personnel. 

The  Polish  Minister  of  Health  believes  that  the  cause  of  the 
epidemic  in  Poland  must  be  sought  outside  Polish  borders  and 
namely  in  the  existence  of  a  permanent  focus  of  infection  in 
Russia  where  according  to  Russian  official  sources  1,600,000 
cases  were  notified  during  1919.  The  Polish  Minister  reports 
that  a  campaign  against  the  epidemic  is  being  carried  on  par- 
ticularly along  the  following  lines :  first,  the  establishment  of  a 
series  of  quarantine  stations  along  the  eastern  borders  of  the 
country;  through  this  line  of  stations  it  is  stated  that  there 
passed  between  November  1,  1918,  and  January  1,  1920, 
652,604  prisoners  of  war  returning  westward  from  Russia,  and 
627,088  reemigrants  flocking  back  to  Poland  from  the  East. 
Secondly,  through  the  establishment  of  epidemic  hospitals  with 
a  total  of  13,077  beds  and  with  a  subsequent  increase  of  some 


98  TYPHUS  FEVER 

7000  beds  between  September,  1919,  and  April  1,  1920.  This 
number  of  beds  does  not,  however,  include  those  in  the  military 
hospitals  at  the  front.  Thirdly,  by  the  establishment  of  mobile 
field  sanitary  columns  294  of  which  it  is  said  they  were  operat- 
ing in  1919,  each  employing  a  disinfecting  apparatus.  These 
columns  carried  oiit  in  the  late  summer  and  autumn  of  1919  a 
mass  cleaning-up  campaign  in  the  epidemic  territory,  and  in  all 
the  counties  of  Poland.  The  Polish  Minister  states  that  "the 
number  of  people  dealt  with  amounted  to  311,374;  72,731 
habitations  were  disinfected,  and  in  addition  to  these,  19,400 
people  were  bathed  by  four  bathing  motorized  columns  of 
Colonel  Gilchrist's  American  Unit,  while  the  units  of  the  Brit- 
ish Society  of  Friends  have  dealt  with  15,860  people  and  2800 
habitations."  In  addition  to  these  measures  the  report  states 
railway  stations  on  all  Polish  Unes  are  being  cleaned  once 
weekly  and  the  railway  cars  are  being  disinfected  at  three 
points.  The  erection  of  public  bathing  and  delousing  places  is 
also  being  encouraged. 

Action  by  the  League  of  Red  Cross  Societies 

Owing  to  the  grave  representations  presented  to  the  League 
of  Red  Cross  Societies  regarding  the  wide  prevalence  of  typhus 
fever  in  Poland  and  the  danger  of  its  spread  westward  across 
Europe,  it  was  decided  that  the  League  should  interest  itself  in 
the  control  of  this  disease  as  an  emergency  relief  measure.  The 
importance  of  this  step  was  particularly  emphasized  by  the 
urgent  request  made  to  the  League  by  the  Polish  Minister  of 
Health  for  assistance  in  preventing  the  spread  of  the  disease 
westward,  and  in  the  suppression  of  the  epidemic  in  Poland 
itself. 

At  a  conference  held  in  Paris  in  June,  1919,  at  which  the 
Minister  of  Public  Health  of  Poland,  then  Dr.  Janiszewski,  Dr. 
Ludwik  Rajchman,  Mr.  W.  Frank  Persons,  Director  of  De- 
partment of  Organization,  League  of  Red  Cross  Societies,  and 
the  writer,  were  present,  the  Minister,  in  a  written  statement, 
requested  that  the  League  of  Red  Cross  Societies  should  assist 
the  Polish  government  in  its  campaign  against  typhus,  and 


THE  SERBIAN  EPIDEMIC  99 

presented  two  proposals  in  this  connection:  first,  that  the 
League  of  Red  Cross  Societies  should  take  over  the  manage- 
ment of  two  lines  of  sanitary  cordon  (permanent  and  mobile) 
on  the  eastern  frontier  of  Poland,  organizing  those  stations 
which  were  not  yet  working;  secondly,  that  the  Ministry  of 
Public  Health  should  conduct  a  campaign  on  the  territory  of 
the  late  Congress  Poland  and  Galicia,  the  Ministry  applying  to 
the  Supreme  Economic  Council  for  the  acquisition  of  necessary 
supplies;  and  that  the  League  of  Red  Cross  Societies  should 
help  the  Ministry  in  obtaining  the  services  of  suitable  salaried 
personnel.  In  the  second  proposal,  the  Minister  stated,  — 
'Hhat  I  am  most  anxious  to  see  a  very  close  cooperation  be- 
tween the  League  and  our  own  public  health  service,  and  this  is 
the  reason  why  I  am  bringing  forward  now  a  new  proposition 
which  we  did  not  discuss  at  our  meeting  this  afternoon,  but 
which  appears  to  me  to  secure  that  end  better  than  the  first 
scheme.  It  would  consist  in  the  following:  (1)  the  Ministry  to 
obtain  supplies  from  the  Economic  Council  as  under  the  first 
alternative;  (2)  the  Ministry  would  organize  a  Central  Com- 
mittee for  fighting  typhus  in  Poland.  This  Committee  would 
appoint  one  delegate  who  conjointly  with  one  delegate  of  the 
League  of  Red  Cross  Societies  would  conduct  the  whole  action 
of  combating  typhus  in  Poland  in  accordance  with  the  scheme 
of  organization  propounded  in  the  annexed  memorandum." 

In  connection  with  assisting  the  Polish  Minister  to  obtain 
personnel,  Colonel  H.  L.  Gilchrist  of  the  United  States  Army 
Medical  Service,  who  had  had  wide  experience  in  disinfesting 
troops,  having  been  in  command  of  such  work  in  the  American 
Expeditionary  Forces  in  France  subsequent  to  the  Armistice, 
was  invited  to  meet  the  Polish  Minister  of  Health  at  one  of 
these  conferences  with  the  idea  of  enlisting  his  services  and 
those  of  his  sanitary  detachment  in  connection  with  the  anti- 
typhus  campaign  in  Poland.  In  a  previous  conference  held 
with  Mr.  Herbert  Hoover,  American  representative  of  the 
Supreme  Economic  Council,  and  representatives  of  the  League 
of  Red  Cross  Societies,  it  had  been  agreed  that  the  Supreme 
Economic  Council  would  interest  itself  in  securing  for  Poland 


100  TYPHUS  FEVER 

necessary  sanitary  and  medical  supplies  from  the  surplus  stores 
of  the  United  States  Army,  and  that  the  League  of  Red  Cross 
Societies  would  interest  itself  in  attempting  to  obtain  the  med- 
ical and  sanitary  personnel  desired  by  the  Polish  Minister.  As 
the  matter,  however,  seemed  to  be  an  urgent  one,  Mr.  Hoover, 
at  the  same  time  that  he  arranged  for  the  sale  to  the  Polish 
government  of  these  supplies,  also  presented  to  the  President 
of  the  United  States,  at  the  time  of  his  departure  from  France, 
the  question  of  the  detail  of  Colonel  Gilchrist  and  his  sanitary 
detachment  for  work  in  Poland,  and  this  officer  and  his  de- 
tachment were  subsequently  ordered  by  the  Secretary  of  War 
of  the  United  States  for  assignment  to  the  Polish  Minister  of 
Health  for  duty.  Unfortunately,  it  apparently  was  not  recog- 
nized that  the  Pohsh  Minister  of  Health  did  not  have  jurisdic- 
tion over  much  of  the  territory  of  Poland  in  which  typhus  was 
at  its  worst,  such  territory  being  under  mihtary  authority; 
hence  the  services  of  this  sanitary  detachment  were  only  avail- 
able in  Congress  Poland  where  the  Polish  Minister  of  Health 
had  jurisdiction. 

The  sanitary  and  hospital  supplies  purchased  by  Poland  on 
credit  at  this  time  for  the  epidemic  campaign  from  the  Ameri- 
can Liquidation  Board  alone  were  valued  at  a  greatly  reduced 
price  at  four  million  dollars.  These  supplies  required  thirty- 
two  trains  each  of  over  fifty  cars  to  transmit  the  material  into 
Poland.  Included  in  this  equipment  were  the  following  impor- 
tant items :  all  the  steam  steriUzers  which  were  not  used  by  the 
American  Forces  in  France;  27  mobile  steam  laundries;  500 
mules  with  harnesses,  hundreds  of  carts,  drags,  etc.;  10,000 
beds;  40,000  sheets,  blankets,  and  pillow  slips;  40,000  towels; 
100  tons  of  soap;  17  motorized  bath  plants;  300  portable  bath- 
ing plants;  4000  Serbian  barrels;  50  tons  of  washing  soda;  1 
million  suits  of  cotton  underclothing;  160  5-ton  Packard 
trucks;  324  Ford  ambulances;  160  Ford  touring  cars;  3  mobile 
machine  shops,  together  with  hundreds  of  other  items  too 
numerous  to  mention. 

In  order  that  the  League  of  Red  Cross  Societies  might  be  in  a 
position  to  act  most  intelligently  in  connection  with  the  re- 


THE  SERBIAN  EPIDEMIC  101 

quests  of  the  Polish  Minister,  the  writer,  as  General  Medical 
Director  of  the  League,  after  consulting  with  the  Chairman  and 
other  officers  of  the  International  Office  of  Pubhc  Health,  and 
the  officials  of  ^  the  British  Ministry  of  Health,  recommended 
that  an  Interallied  Commission  consisting  of  Assistant  Surgeon 
General  Hugh  S.  Gumming  (now  Surgeon  General  of  the 
United  States  Public  Health  Service) ;  Dr.  George  S.  Buchanan, 
Senior  Medical  Officer,  British  Ministry  of  Health;  Dr.  Aldo 
Castellani,  Lieutenant  Colonel  Italian  Medical  Service,  and 
Dr.  F.  Visbecq,  Medecin  principal  de  premiere  classe,  French 
Army,  Service  de  Sante,  be  appointed  to  proceed  to  Poland  for 
the  purpose  of  making  a  careful  investigation  of  the  medical 
and  sanitary  conditions  in  that  country.  This  Commission, 
upon  its  return  from  Poland,  rendered  a  comprehensive  report 
to  the  League,  summarizing  the  knowledge  of  medical  and 
sanitary  conditions  in  that  country,  and  making  recommenda- 
tions of  the  measures  which  should  be  undertaken  and  the 
personnel  and  medical  and  sanitary  supplies  which  should  be 
furnished  for  the  campaign  against  typhus  fever  and  other  in- 
fectious diseases  epidemic  there.  It  also  pointed  out  that  for 
the  protection  of  Eastern  Europe  and  of  other  regions,  it  is 
essential  that  the  Polish  government  should  receive  help  in  the 
fight  against  typhus  and  other  epidemic  diseases,  not  only  in 
Poland  proper,  but  along  the  eastern  frontiers  through  which 
infectious  diseases  are  being  constantly  introduced  by  refugees 
and  prisoners,  and  are  liable  to  spread  immediately  into  the  in- 
terior of  the  country.  On  account  of  the  magnitude  of  the  task, 
the  Director  General  of  the  League  pointed  out  that  the  case 
seemed  to  be  one  which  called  for  active  assistance  from  gov- 
ernments as  well  as  from  voluntary  organizations,  and  that 
it  should  be  frankly  stated  and  generally  understood  that  the 
resources  of  the  Red  Cross  were  insufficient  to  provide  all  the 
assistance  required  by  Eastern  Europe  in  this  great  emergency. 
The  Report  of  this  Medical  Commission  was,  therefore,  pre- 
sented not  only  to  the  national  Red  Cross  societies,  but  also  to 
the  Secretary  of  the  League  of  Nations  and  the  Supreme  Eco- 
nomic Council,  with  the  request  that  all  possible  assistance  be 


102  TYPHUS  FEVER 

given.  A  copy  of  this  Report  was  also  sent  to  the  International 
Offices  of  Public  Health  at  Paris.  The  Committee  of  this  Office, 
after  pointing  out  that  it  understands  ^Hhat  the  League  of  Red 
Cross  Societies  considers  the  necessary  action  to  be  beyond 
what  could  be  undertaken  by  the  Red  Cross  organizations,  and 
that  the  League  has  therefore  presented  the  Report  of  its  Com- 
mission to  the  various  governments  which  are  able  to  help  by 
supplying  material  and  personnel,  and  that  it  has  insisted  upon 
the  necessity  of  the  said  governments  helping  in  as  great  a 
measure  as  possible  and  as  quickly  as  possible  in  the  campaign 
against  typhus  in  Poland  which  the  Polish  government  is  un- 
dertaking," states  that  the  Committee  of  the  International 
Office  fully  associates  itself  with  the  above  suggestions,  being 
convinced  that  the  fight  against  typhus  in  Poland  is  of  the  ut- 
most importance  for  the  protection  of  other  countries  against 
the  propagation  of  this  terrible  disease. 

The  League  then  took  further  action  in  connection  with  the 
Report  of  its  Medical  Commission  and  designated  Mr.  Wil- 
liam C.  Boyden  as  commissioner  to  Poland,  and  Colonel  Henry 
A.  Shaw  as  medical  representative,  who  with  a  medical  staff 
were  sent  to  Poland  to  render  such  assistance  as  was  pos- 
sible for  the  League  of  Red  Cross  Societies  to  give  the  Polish 
government,  and  particularly  to  assist  this  government  in 
carrying  on  an  extensive  campaign  against  typhus  as  had  been 
requested  by  the  Polish  Minister  of  Health.  The  plan  of 
campaign  proposed  included  both  field  and  sanitary  work,  com- 
prising general  disinfestation  of  people  in  badly  infected  dis- 
tricts, with  removal  of  patients  to  infectious  disease  hospitals; 
disinfestation  of  other  inmates  and  disinfection  of  the  houses 
from  which  patients  are  taken;  the  establishment  of  quaran- 
tine and  disinfesting  stations,  particularly  in  relation  to  the 
movement  of  refugees  and  the  disinfection  of  railway  trains 
and  other  vehicles  of  transportation;  as  well  as  the  establishing, 
equipping,  and  running  of  hospitals  for  infectious  diseases;  the 
securing  of  personnel  for  the  sanitary  and  hospital  work,  and 
provision  for  an  educational  campaign  which  would  include  the 
preparation  of  pamphlets  and  circulars  upon  infectious  dis- 


THE  SERBIAN  EPIDEMIC  103 

eases,  printed  in  the  language  of  the  country,  and  practical 
demonstrations  to  be  supplemented  by  cinematographic  exhibi- 
tions on  the  public  health  measures  concerned. 

The  League  also  arranged  with  Dr.  S.  Burt  Wolbach  of 
Harvard  University  and  a  staff  of  seven  members,  which  in- 
cluded Dr.  John  L.  Todd,  associate  professor  of  parasitology  at 
McGill  University,  Dr.  A.  Bacot,  entomologist  of  the  Lister 
Institute,  London,  and  Dr.  Frank  W.  Palfrey,  instructor  in 
medicine  at  Harvard  University,  to  make  thorough  investiga- 
tions regarding  the  aetiology  of  typhus  fever,  particularly  with 
the  hope  that  new  knowledge  might  eventually  be  obtained 
regarding  its  prevention  by  vaccination  and  its  treatment  by 
serum-therapy,  and  the  report  of  this  Commission  has  already 
been  referred  to. 

Response  to  the  Appeal  of  the  League  of  Red  Cross  Societies 

Following  the  appeal  of  the  League  for  assistance  in  Poland 
from  the  national  Red  Cross  societies,  a  generous  response  was 
obtained  from  the  American,  Australian,  Belgian,  British, 
Italian,  Japanese,  Portuguese,  Roumanian,  Serbian,  and 
Spanish  Red  Cross  societies.  Also  in  the  summer  of  1919  the 
British  government  at  the  instance  of  the  Supreme  Economic 
Council  contributed  jointly  with  the  British  Red  Cross,  on  a 
pound  to  pound  basis,  £60,000  for  military  and  civilian  relief 
work  under  the  League  of  Red  Cross  Societies  in  Eastern 
Europe.  Twenty  thousand  pounds  of  this  amount  were  made 
available  for  Poland.  The  British  Red  Cross  Society  had  al- 
ready expended  one  hundred  thousand  pounds  on  hospital  re- 
quirements, according  to  the  Report  on  Economic  Conditions 
in  Central  Europe,  transmitted  with  Sir  William  Goode's 
despatch  of  January  1,  1920,  and  a  further  one  hundred  thou- 
sand pounds  out  of  British  credits  was  provided,  which  was  to 
be  used  for  the  purchase  of  drugs  and  medical  accessories. 

The  American  Red  Cross  has  been  pursuing  its  activities  in 
Poland  under  the  direction  of  its  commissioner.  Lieutenant 
Colonel  A.  J.  Chesley,  since  early  in  1919.  Its  personnel  at 
the  present  time  in  Poland,  according  to  the  statements  of 


104  TYPHUS  FEVER 

Lieutenant  Colonel  Kendall  Emerson,  Deputy  Commissioner 
to  Europe  of  the  American  Red  Cross,  numbers  187.  Since 
October  1,  1919,  378  carloads  of  supplies  have  been  shipped  to 
Poland.  These  include  such  articles  as  medical  and  hospital 
supplies,  food,  clothing,  and  motors  for  transportation.  The 
relief  work  of  the  American  Red  Cross  has  included  the  general 
distribution  of  clothing  to  refugees,  as  well  as  medical  care 
and  advice;  maintaining  and  operating  delousing  plants,  and 
clinics  and  dispensaries;  the  equipping  of  hospitals  and  the 
establishment  and  operation  of  hospitals. 

In  addition  the  American  Red  Cross  has  heartly  cooperated 
with  the  plans  and  activities  of  the  League  of  Red  Cross  Socie- 
ties relating  to  Poland  and  Eastern  Europe,  having  donated 
1500,000  to  the  League  to  cover  cost  of  investigations  and  sur- 
veys. It  has  also  set  aside  $400,000  of  its  own  funds  for  ex- 
penditure in  Poland  in  accordance  with  the  League's  program. 

Further  Need  of  Personnel  and  Supplies 

In  a  recent  report  made  to  the  General  Council  of  the  League 
of  Red  Cross  Societies  by  the  writer,  it  was  emphasized  that  fur- 
ther assistance  is  urgently  needed,  since  typhus  fever  in  certain 
districts  of  Poland  is  still  on  the  increase,  and  the  manner  in 
which  the  national  Red  Cross  societies  can  still  be  of  particular 
assistance  was  reiterated  as  follows:  in  relation  to  personnel,  it 
is  suggested  that  physicians  be  furnished  who  should  prefer- 
ably have  a  special  knowledge  of  infectious  diseases  and  their 
treatment.  These  physicians  would  be  stationed  in  the  dif- 
ferent hospitals  for  infectious  diseases  already  established  in 
Poland;  other  physicians  should  be  bacteriologists  with  partic- 
ular knowledge  of  public  health  laboratory  work,  while  others 
should  have  special  knowledge  of  field  sanitation  and  should  be 
preferably  medical  men  trained  as  health  officers  or  at  least 
graduates  of  schools  for  health  officers;  sanitary  engineers  with 
special  knowledge  of  water  supplies  and  the  sterilization  of 
drinking  water  will  also  be  required;  nurses  trained  partic- 
ularly for  work  in  infectious  diseases  hospitals,  and  others 
trained  for  visiting  and  public  health  nursing  are  also  greatly 


THE  SERBIAN  EPIDEMIC  105 

needed.  The  writer  has  been  informed  by  the  PoHsh  Minister 
of  Health  that  foreign  units  rather  than  individual  personnel  of 
the  nature  described  above  are  particularly  desired.^  Complete 
equipment  for  hospitals  for  infectious  diseases  is  also  urgently 
required. 

The  Interallied  Medical  Commission  of  the  League  sent  to 
Poland  also  reported  that  the  following  supplies  are  indispen- 
sable for  carrying  on  the  campaign:  soap,  outer  garments  (for 
refugees  and  convalescents),  linen,  blankets,  outer  garments 
(particularly  for  patients),  hospital  equipment  and  mobile 
hospitals,  drugs,  various  types  of  vehicles,  delousing  plants, 
both  stationary  and  mobile;  and  particularly  tools  and  material 
for  construction  of  wooden  buildings. 

Importance  of  Further  Administrative  Measures  in 
Combating  the  Epidemic 

In  a  recent  report  made  in  March,  1920,  Colonel  Gilchrist 
writes:  ^' After  seven  months  of  active  work  in  Poland  as 
the  Commanding  Officer  of  the  American  Typhus  Fever  Ex- 
pedition ...  I  am  convinced  that  before  typhus  fever  can 
be  eliminated  from  Poland  the  entire  matter  will  have  to  be 
placed  under  the  control  of  a  commission  preferably  inter- 
national .  .  .  which  will  have  to  have  absolute  control  over  all 
matters  pertaining  to  the  elimination  of  typhus  fever  in  the 
country." 

It  has  been  pointed  out  that  the  Polish  Minister  of  Health 
has  not  had  jurisdiction  over  much  of  the  territory  in  which 
typhus  has  particularly  prevailed,  such  territory  being  under 
military  administration,  and  that  therefore  there  had  not  been 
as  great  cooperation  and  efficiency  in  prosecuting  the  cam- 
paign as  was  desirable.  Eecently,  however,  the  Polish  govern- 
ment has  appointed  Colonel  Godlewski  as  Chief  Epidemic 
Commissary,  whose  power  it  is  said  will  extend  over  the  whole 
of  Poland  including  the  country  both  under  civil  and  military 
administration.    Provided  therefore  that  the  Polish  govern- 

1  The  League  of  Red  Cross  Societies  is  at  the  present  time  about  to  issue  a  further 
appeal  in  connection  with  the  rehef  of  Poland. 


106  TYPHUS  FEVER 

ment  will  seriously  impel  and  support  the  campaign  there 
would  seem  to  be  every  reason  to  feel  that  under  the  efficient 
direction  of  Colonel  Godlewski,  who  has  been  placed  in  entire 
charge  of  this  work,  assisted  by  Colonel  Shaw  in  charge  of  the 
inspection  service,  Colonel  Gilchrist  in  charge  of  bathing  and 
delousing  work,  and  Colonel  Chesley  in  charge  of  distribution 
of  American  supplies,  we  may  look  forward  with  confidence  to 
the  administration  of  the  campaign.  The  present  plan  of  cam- 
paign includes  a  comprehensive  scheme  for  cleaning  up  central 
Poland  inasmuch  as  all  reports  indicate  that  the  disease  has  ob- 
tained a  firm  foothold  throughout  the  entire  territory  of  Poland 
and  is  no  doubt  spreading  more  or  less  extensively  from  these 
foci.  It  is  the  intention,  however,  that  there  should  be  no  re- 
laxation but  an  additional  prosecution  of  the  work  of  excluding 
the  disease  along  the  eastern  and  southern  frontiers. 

Poland,  however,  has  so  many  serious  problems  confronting 
her  that  neither  many  of  the  governmental  officials  nor  the 
people  at  large  have  as  yet  become  thoroughly  and  sufficiently 
aroused  to  the  importance  and  necessity  of  ridding  the  country 
of  the  disease.  The  epidemic  has  not  been  sufficiently  prevalent 
or  the  mortality  sufficiently  high  as  to  convince  the  people  of 
the  necessity  for  an  intensive  efficient  anti-typhus  campaign 
and  of  the  inevitable  inconveniences  which  must  accompany 
it.  Indeed  the  general  attitude  of  many  of  the  people  in  Po- 
land is  hostile  to  anti-typhus  work,  perhaps  because  often 
during  the  German  occupation  the  people  were  compelled  to 
submit  to  the  necessary  delousing  measures  which  were  ap- 
plied by  the  Germans  with  military  severity.  As  has  been  em- 
phasized in  this  article  in  discussing  the  Serbian  epidemic,  one 
of  the  most  important  features  in  the  suppression  of  this  epi- 
demic was  the  cooperation  of  the  people  in  aU  efforts  to  eradi- 
cate the  disease.  In  Serbia,  however,  the  disease  was  general, 
and  the  very  great  majority  of  the  families  in  the  entire  country 
has  suffered  from  it.  In  Serbia  also  the  mortality  was  in  the 
neighborhood  of  50  per  cent,  whereas  in  the  Polish  epidemic  it 
has  scarcely  been  above  9  per  cent.  As  Colonel  Shaw  writes,  it 
is  manifestly  impossible  to  compel  a  whole  population  to  sub- 


THE  SERBIAN  EPIDEMIC  107 

mit  against  their  will  to  delousing  measures.  The  first  problem 
is  to  change  their  mental  attitude  so  that  they  will  be  willing  to 
cooperate  and  spread  the  doctrine  of  the  campaign.  For  this 
reason  it  has  been  recommended  that  there  should  be  instituted 
as  an  important  part  of  the  new  campaign  a  comprehensive 
plan  of  education  regarding  the  prevention  of  typhus  designed 
to  reach  practically  the  entire  population.  Particular  effort 
will  be  made  to  arouse  and  stimulate  the  activities  of  the  people 
generally  through  religious  organizations,  schools,  the  press, 
through  cinema  exhibitions,  relief  organizations,  magistrates, 
and  other  officials  of  towns  and  villages,  and  prominent  busi- 
ness men.  In  this  connection  a  play  has  been  written  by  Major 
Richard  Taylor  of  the  staff  of  the  League  of  Red  Cross  Socie- 
ties, which  is  now  being  performed  in  Poland.  This  play,  which 
is  in  the  form  of  a  drama,  depicts  the  terror  of  this  widespread 
disease,  particularly  among  the  poorer  classes  of  the  population 
in  Poland,  and  at  the  same  time  it  shows  how  it  may  be  fought 
successfully  by  proper  measures.  One  of  the  most  interesting 
scenes  depicts  the  arrival  of  a  relief  commission  for  health  work 
in  a  village  which  is  ravaged  by  typhus. 

Dr.  Buchanan  of  the  Ministry  of  Health  of  Great  Britain, 
and  a  member  of  the  Interallied  Medical  Commission  of  the 
League  of  Red  Cross  Societies  to  Poland,  since  his  return  from 
Poland  has  not  relaxed  his  efforts  in  Great  Britain  in  connec- 
tion with  the  medical  relief  of  that  country.  Very  recently  at 
the  British  Ministry  of  Health  an  International  Health  Con- 
ference was  held  at  the  instigation  of  the  Council  of  the  League 
of  Nations,  at  the  sessions  of  which  relating  to  Poland  Dr. 
Buchanan  presided.  Representatives  of  the  Polish  govern- 
ment and  of  the  League  of  Red  Cross  Societies  furnished  this 
Conference  with  information  concerning  Poland's  needs  in  com- 
bating the  typhus  scourge;  and  the  Conference  agreed  that 
action  by  the  League  of  Nations  was  necessary.  The  measures 
necessary  to  combat  this  epidemic  on  a  large  scale  were  set 
forth,  namely,  the  establishment  of  sanitary  cordons,  hospitals, 
delousing  stations,  the  provision  of  food  and  fuel;  and  expert 
direction  of  the  work;  and  it  was  recommended  that,  whenever 


108  TYPHUS  FEVER 

possible,  surplus  war  materials  be  secured  for  use  in  Poland. 
The  task  of  furnishing  medical  and  sanitary  personnel,  nurses, 
and  hospital  units  and  certain  supplies  was  to  be  carried  on 
under  the  auspices  of  the  League  of  Red  Cross  Societies.  Reso- 
lutions relating  to  these  activities  were  passed  before  the  Con- 
ference adjourned.  The  League  of  Nations  in  connection  with 
one  of  these  resolutions  has  already  appointed  a  Tjrphus  Com- 
mission with  Lieutenant  Colonel  Vaughan-Morgan  as  Chief 
Commissioner,  and  Dr.  Norman  White  as  Medical  Commis- 
sioner. The  League  of  Red  Cross  Societies  will  also  be  repre- 
sented upon  this  Commission. 

In  view  of  this  additional  governmental  assistance,  we  may 
then  have  greater  hope  that  the  epidemic  will  be  soon  brought 
under  control. 

Nevertheless,  writing  at  this  time,  the  writer  feels  it  necessary 
to  emphasize  the  fact  that  the  anti-typhus  campaign  in  Poland 
is  even  not  yet  being  prosecuted  by  the  Polish  government  in 
an  energetic  and  satisfactory  manner.  While  the  greatest  sym- 
pathy is  due  the  Polish  people  and  many  of  its  officials  for  the 
terrible  plight  in  which  Poland  has  been  placed  by  the  war 
and  on  account  of  the  several  very  grave  war  problems  which 
she  still  has  to  face,  all  concerned  in  connection  with  this  epi- 
demic must  nevertheless  realize  the  fact  that  at  no  time  during 
the  past  four  years  has  the  anti-typhus  campaign  been  pur- 
sued with  that  activity  and  energy  which  is  desirable  and 
necessary  to  overcome  the  epidemic.  Today  the  Polish  govern- 
ment almost  overwhelmed  with  military  problems  is  less  able 
than  ever  successfully  to  cope  with  the  situation  and  foreign 
assistance  seems  imperative  if  this  is  to  be  accomplished.  The 
government  of  Poland  therefore  not  being  in  a  position.to  deal 
successfully  with  the  epidemic,  an  opportunity  is  obviously  af- 
forded to  the  League  of  Nations,  in  addition  to  the  League  of 
Red  Cross  Societies,  to  extend  aid  in  this  connection  in  that 
country.  It  should  however  be  realized  that  the  mere  furnish- 
ing of  supplies  is  not  sufficient.  If  an  additional  large  amount  of 
sanitary  equipment  and  vast  hospital  stores  are  sent  to  Poland 
without  sufficient  and  efficient  personnel  to  make  proper  use  of 


THE  SERBIAN  EPIDEMIC  109 

them,  the  effort  in  the  hght  of  past  experience  is  liable  to  avail 
but  little.^  It  therefore  would  seem  to  be  exceedingly  desirable 
that  the  League  of  Nations  should  extend  its  efforts  not  only  to 
obtaining  such  material  but  should  also  particularly  endeavor 
to  arrange  that  a  vigorous  and  really  efficient  anti-typhus  cam- 
paign be  waged  and  supported  in  every  way  practicable  by  the 
Polish  government. 

Typhus,  however,  is  no  longer  a  Polish  question.  It  has  be- 
come a  world-wide  question,  demanding  energetic  measures. 
Besides  the  possibility  of  its  spread  to  Western  Europe  and 
even  by  occasional  cases  across  the  Atlantic,  and  in  addition  to 
the  industrial  and  social  unrest  which  accompanies  it,  there  is 
the  fact  that  the  economic  rehabilitation  of  Eastern  Europe 
cannot  proceed  satisfactorily  until  this  disease  is  stamped  out. 
Not  only  is  it  sapping  the  resources  of  Poland,  it  is  causing 
other  nations  to  set  up  barriers  against  her;  it  is  fostering  isola- 
tion in  its  most  deadly  form.  For  example,  every  person  arriv- 
ing in  France  from  typhus-infected  areas  in  Eastern  Europe  is 
liable  to  be  subject  to  medical  inspection  and  quarantine.  In 
Great  Britain  regulations  have  been  recently  issued  by  the 
Ministry  of  Health  extending  and  strengtheniiig  the  powers  of 
port  and  riparian  sanitary  authorities  against  the  introduction 
of  this  disease.  At  Cherbourg  and  Rotterdam  quarantine  and 
disinfestation  of  all  second  and  third  class  passengers  coming 
from  countries  east  of  Switzerland  and  proceeding  to  the 
United  States  is  already  required.  Nations  are  tightening,  in- 
stead of  relaxing,  the  cordon  of  their  frontiers. 

It  is  costing  the  world  more  to  tolerate  typhus  than  to  elimi- 
nate it.  It  is  a  disease  which  spreads  very  rapidly  and  which  is 
very  deadly;  but  it  is  one  which  can  be  checked  with  sufficient 
men  and  material.  The  cost  of  "  cleaning  up  "  Poland  would  be 
less  than  the  loss  typhus  now  occasions. 

If  the  world  does  not  fight  typhus  in  Poland,  it  may  soon 
have  to  be  fought  not  in  those  countries  alone  where  it  is 
liable  to  become  epidemic  but  in  others  in  which  isolated  cases 
of  the  disease  will  from  time  to  time  slip  through  quarantine 
and  set  up  new  centers  of  infection. 

^  See  pages  99  and  100  of  this  Report. 


PART    II 

CLINICAL  OBSERVATIONS  ON  TYPHUS  FEVER 
IN  SERBIA  IN  19151 

By  GEORGE  C  SHATTUCK 

Prefatory  Note 

As  clinical  member  of  the  American  Red  Cross  Sanitary  Com- 
mission it  became  my  duty  to  study  the  clinical  manifestations 
and  treatment  of  typhus  fever. 

Near  Skoplje  or  Uskub,  occupying  the  buildings  formerly 
used  by  the  Military  Academy,  was  situated  the  institution 
known  as  the  Lady  Paget  Hospital,  superintended  by  Lady 
Paget,  with  a  staff  of  doctors  of  the  British  Red  Cross  in  charge 
of  Dr.  Maitland.  Before  our  arrival,  early  in  May,  this  hospital 
had  already  become  one  of  the  principal  fever  hospitals  of  Ser- 
bia. It  was  proposed  that  Dr.  Zinsser,  our  bacteriologist,  Dr. 
Sellards,  our  clinical  laboratory  member,  and  I  should  pursue 
our  investigations  at  the  Lady  Paget  Hospital  and  we  gladly 
availed  ourselves  of  the  opportunity. 

The  hospital  consisted  of  two  large  three-story  buildings  de- 
voted partly  to  wards  and  partly  to  quarters  for  the  staff,  and 
three  pavilions,  in  each  of  which  there  were  two  large  wards. 
One  of  these  pavilions  was  put  in  my  charge.  Its  wards  ac- 
commodated ninety  patients  without  overcrowding. 

There  were  in  May  about  four  hundred  patients  in  the  hos- 
pital. New  patients  entered  daily  in  variable  numbers,  gen- 
erally a  few  at  a  time,  but  on  one  occasion  eighty  new  patients 
arrived,  and  about  forty  of  these  were  sent  to  my  wards. 

In  the  spring  most  of  the  patients  in  the  hospital  were  suf- 
fering from  typhus  or  its  sequelae,  but  there  were  many  cases 
of  relapsing  fever,  a  certain  proportion  of  tuberculosis,  and  a 
small  number  of  cases  of  other  diseases.  As  the  season  ad- 
vanced the  proportion  of  typhus  declined.    Relapsing  fever 

'  Prepared  in  1916  as  part  of  report  of  work  done  as  a  member  of  the  American  Red 
Cross  Sanitary  Commission  to  Serbia.     Revised  for  publication  April,  1920. 

Ill 


112  CLINICAL  OBSERVATIONS 

increased  for  a  short  time  and  then  rapidly  diminished,  so  that 
by  the  middle  of  July  there  were  very  few  fresh  cases  of  either 
disease  in  the  hospital.  Malaria  was  increasing  rapidly,  and 
dysentery  of  a  mild  form  was  becoming  common.  About  this 
time  I  left  the  Paget  Hospital  at  the  request  of  Dr.  Strong  to 
take  up  other  work. 

Just  before  we  began  work  Lady  Paget  and  Dr.  Maitland 
sailed  for  England,  leaving  Dr.  E.  Belhngham  Smith  in  charge 
of  the  hospital.  Through  the  courtesy  of  Dr.  Smith,  and  of  Dr. 
A.  H.  Holmes,  another  member  of  the  staff,  I  was  allowed  to 
examine  patients  and  to  take  notes  in  their  wards. 

The  autopsies  were  performed  by  Dr.  Zinsser,  until  he  re- 
turned home  in  July,  after  which  I  performed  a  number  of  them. 

The  urinalyses  were  performed  jointly  by  Dr.  Sellards  and 
me.  Dr.  Sellards  made  all  the  Sahli  haemoglobin  determina- 
tions, the  red  and  white  counts,  most  of  the  blood  film  exam- 
inations, and  the  Widal  tests. 

Dr.  Dalyell,  the  British  bacteriologist,  kindly  examined  a 
number  of  blood  films  for  the  spirillum  of  relapsing  fever,  and 
was  helpful  in  many  ways. 

To  all  of  those  mentioned  and  to  the  members  of  the  British 
Staff  in  particular,  it  is  a  pleasure  to  express  thanks. 

Literature  on  Typhus 

The  distinguished  men  of  medicine  who  have  made  impor- 
tant contributions  to  the  knowledge  of  typhus,  since  ft  was 
clearly  differentiated  from  typhoid  by  Gerhard,  are  too  numer- 
ous to  mention  here. 

The  clinical  descriptions  of  Gerhard,^  WiUiam  Jenner,^ 
Murchison,^   Curschmann,^  Thoinot,^   and  Moore  ^  are  pre- 

1  Gerhard:  Am.  Jour.  Med.  Sc,  1837,  xix,  289;  xx,  289. 

2  Jenner:  Med.  Times  and  Gaz.,  Lond.,  1849,  xx,  401,  418,  456;  xxi,  15,  113,  135,  233, 
453. 

3  Murchison:  Medico-Chir.  Trans.,  Lond.,  1850,  xxxiii,  23.  Continued  Fevers  of 
Great  Britain,  3d  ed.,  ed.  by  Cayley,  Lond.,  1884. 

4  Curschmann:  Nothnagel's  Encyc.  of  Pract.  Med.,  Eng.  trans.,  ed.  by  Osier,  Phil, 
and  Lond.,  1901. 

^  Thoinot:  Ann.  d'Hyg.,  Par.  1915,  4th  Series,  xxiii,  6. 

^  Moore:  Allbutt  and  RoUeston,  System  of  Medicine,  Lond.,  1906,  ii. 


TYPHUS  IN  SERBIA  113 

eminently  good.  Again,  in  the  Gulstonian  Lecture/  on  the 
acute  specific  diseases,  in  which  characteristics,  resemblances, 
and  differences  are  compared,  Jenner's  mastery  of  the  subject 
is  revealed.  Stokes  ^  recognized  differences  between  typical 
typhoid  and  exanthematic  typhus  but,  finding  the  "typhoid 
state"  common  to  both,  he  believed  to  the  last  that  they  were 
varieties  of  the  same  disease.  Nevertheless,  his  observations 
on  circulatory  conditions  in  these  fevers  are  of  great  value. 

The  "Clinical  Reports  on  Continued  Fevers"  comprising 
a  careful  analysis  of  164  cases,  by  Austin  Flint,^  contain  im- 
portant observations  on  circulatory  conditions  and  causes  of 
death,  and  also  an  able  summing  up  of  the  evidence  then  avail- 
able for  and  against  the  view  that  typhus  and  typhoid  fever  are 
different  diseases.  He  favored  the  conclusion  that  they  were 
different  but  remained  skeptical. 

The  pathology  of  typhus  was  first  well  described  by  Ger- 
hard,* was  discussed  in  detail  by  Murchison,^  and  summarized 
by  Moore  *^  and  Thoinot.^  Aschoff^  and  Prowazek  ^  more 
recently  studied  it  anew. 

Important  points  for  treatment  were  brought  out  by  Ger- 
hard,^°  Stokes,^^  Murchison,^^  and  Castelloi  (quoted  by  Doty^^). 
Curschmann,^*  Moore,^^  and  Doty^^  admirably  discussed  this 
aspect  of  the  subject. 

An  extensive  bibliography  can  be  found  in  Murchison's 
book^^  and  a  list  of  the  recent  literature  on  typhus  with  ab- 

1  Jenner:  Gulstonian  Lectures,  Lond.,  March,  1853. 

2  Stokes:  Diseases  of  the  Heart  and  Aorta,  Lond.,  1854;  Lectures  on  Fever,  Deliv.  at 
Meath  Hosp.,  Dubhn,  ed.  in  Phil.,  1876. 

5  Flint:  Clinical  Reports  on  Continued  Fever,  Phil.,  1855. 

^  Gerhard:  loc.  cit. 

^  Murchison:  loc.  cit. 

^  Moore:  loc.  cit. 

^  Thoinot:  loc.  cit. 

8  Aschoff:  Med.  KUn.,  1915,  ii,  798;   Abst.  Trop.  Dis.  Bull.,  1916,  vii,  148. 

^  Prowazek:  Original,  Beitr.  z.  Klin.  d.  Infections-krankheiten  u.  z.  Immunitatsfor- 
schung,  iv.  No.  1;   Med.  Rec,  N.  Y.,  1915,  Ixxxviii,  21.    Editorial. 
1"  Gerhard:  loc.  cit.  "  Stokes:  loc.  cit. 

12  Murchison:  loc.  cit. 

"  Doty:  Therapeusis  of  Internal  Diseases,  Forchheimer,  N.  Y.,  1913,  ii. 
^*  Curschmann:  loc.  cit.  ^^  Moore:  loc.  cit. 

"  Murchison:  loc.  cit. 


114  CLINICAL  OBSERVATIONS 

stracts  of  many  of  the  articles  was  published  in  the  Tropical 
Diseases  Bulletin  ^  of  March  15,  1916. 

Many  valuable  articles  have  appeared  recently  about  typhus 
epidemics  in  1914  and  1915  and  several  are  of  unusual  interest 
from  the  clinical  standpoint.  In  this  connection  the  follow- 
ing names  require  mention:  Maitland,-  Gastou,^  Jurgens,^ 
Michaud,^  Milhit,^  Siebert/  and  Weiner.^  Foster  ^  described 
an  epidemic  in  the  Philippine  Islands,  Michie^°  published  an 
account  of  his  observations  in  Mexico,  and  BrilP^  has  compared 
the  endemic  typhus  of  New  York  with  the  more  virulent  form 
seen  in  epidemics. 

Usual  Course  of  the  Disease 

An  epitome  of  the  typical  course  of  typhus  may  be  useful  for 
comparison  with  the  observations  discussed  later  in  this  article. 

The  course  of  the  disease  has  been  divided  into  periods  as 
follows:  (1)  incubation;  (2)  invasion;  (3)  nervous  excitement;  (4) 
nervous  depression;  (5)  defervescence;  (6)  convalescence. 

The  duration  of  the  incubation  period  or  latent  stage  is  given 
by  different  observers  as  from  five  to  twenty-one  days.  Ac- 
cording to  Minkine  it  averages  eight  days;  according  to  Netter, 
eleven;  and  according  to  Moore,^^  usually  about  twelve  days. 
During  this  period  there  are  no  recognized  symptoms. 

The  stage  of  invasion  lasts  from  three  to  five  days  during 
which  the  temperature  rises  rapidly  with  slight  morning  remis- 
sions.   The  onset  of  symptoms  is  abrupt.   A  sense  of  extreme 

1  Bibliog.  of  recent  work,  typhus.   Trop.  Dis.  Bull.,  1916,  vii,  137. 

2  Maitland:  Brit.  Med.  Jour.,  1915,  p.  283. 
^  Gastou:  Rev.  de  med.,  1915,  xxxiv,  559. 

*  Jurgens:    Zeitsch.  f.  arzt.  Fortbild.,  1915,  xii,  201;  Berl.  klin.  Wchnschr., 

1915,  lii,  654. 
^  Michaud:  Rev.  med.  de  la  Suisse  romande,  1914,  xxxiv,  554. 

6  Milhit:  Progres  med.,  3d  Series,  No.  32,  1915,  p.  382. 

7  Siebert:  Berl.  Klin.,  1916,  xxvi,  1. 

8  Weiner:  Wien.  klin.  Wchnschr.,  1915,  xxviii,  407. 

9  Foster:  Arch.  Int.  Med.,  1915,  xvi,  363. 

i»  Michie:  Med.  Rec,  N.  Y.,  1915,  Ixxxvii,  214. 

11  Brill:  ibid.,  Ixxxviii,  914. 

12  Moore:  loc.  cit. 


TYPHUS  IN  SERBIA  115 

weakness  often  obliges  the  patient  to  remain  in  bed  on  the 
third  day. 

The  stage  of  nervous  excitement  is  characterized  in  severe 
cases  by  signs  of  acute  toxaemia  and  by  the  development  of  the 
eruption  which  generally  comes  on  the  fourth  or  fifth  day. 
This  period  lasts  two  or  three  days  and  is  followed  by  the  stage 
of  nervous  depression  which  is  characterized  by  the  "typhoid 
state."  This  condition  does  not  develop,  however,  in  mild  or 
abortive  cases. 

Defervescence  is  generally  rapid,  but  is  very  variable  in 
duration  and  is  accompanied,  in  favorable  cases,  by  marked 
diminution  in  the  symptoms  of  toxaemia.  Failure  to  show  such 
improvement  when  the  temperature  is  falling  in  the  usual  way 
is  universally  regarded  as  a  most  unfavorable  sign.  It  is  at 
this  stage  or  later  that  most  of  the  deaths  occur. 

The  duration  of  the  fever  was  found  by  Murchison  ^  to  aver- 
age between  thirteen  and  fourteen  days,  in  cases  that  recover. 
In  his  fatal  cases  it  averaged  fourteen  to  fifteen  days. 

Material  and  Plan  of  Work 

Several  hundred  cases  were  observed  and  of  these  over  100 
were  studied  in  detail.  Autopsies  were  performed  in  twenty 
cases.  In  three  of  these  cases  lesions  of  other  diseases  were 
found  and  the  evidence  of  typhus  is  not  absolutely  certain. 
Many  of  the  cases  which  came  to  autopsy  were  not  under  my 
care  during  life,  and  regarding  these  cases  I  have  little  or  no 
clinical  data. 

Work  was  planned  along  the  following  lines:  firstly,  to  ob- 
serve the  signs  and  symptoms  with  especial  reference  to  diag- 
nosis; secondly,  to  classify  the  varieties  of  the  disease  on  the 
basis  of  prominent  symptoms;  and  thirdly,  to  determine  the 
cause  of  death  as  indicated  by  symptoms,  autopsy  findings,  or 
both,  with  the  object  of  improving  treatment. 

Case  reports  have  been  appended  to  illustrate  the  observa- 
tions made.  These  cases  have  been  grouped  under  the  follow- 
ing heads : 

^  Murchison:  loc.  cit. 


116  CLINICAL  OBSERVATIONS 

(a)  Typhus  with  recovery  —  13  cases. 

(6)  Typhus  followed  by  death  —  with  autopsy  —  20  cases. 

(c)   Typhus  followed  by  death  —  no  autopsy  —  2  cases. 

{d)  Diagnostic  problems  —  7  cases. 

An  index  and  list  of  numbers  has  been  provided.  It  precedes 
the  case  reports.  All  case  numbers  mentioned  in  the  text  refer 
to  the  illustrative  cases. 

Observations 
I.   Fever 

Of  the  onset  there  is  little  to  say.  In  two  mild  cases  which 
developed  in  the  hospital  the  fever  rose  with  moderate  morn- 
ing remissions,  reached  its  maximum  in  four  or  five  days,  main- 
tained a  high  level  for  a  few  days,  and  dropped  by  rapid  lysis 
with  marked  morning  remissions  to  normal  again.  In  these 
cases  the  patient's  strength  returned  quickly  and  convalescence 
was  short. 

Ordinary  cases  differed  from  these  in  greater  severity  of 
symptoms,  more  prolonged  high  fever,  greater  prostration,  and 
slower  return  of  strength. 

Statements  of  the  patients  about  duration  of  illness  were  not 
considered  of  much  value  because  the  patient  was  often  too  ill 
to  given  an  intelligent  answer,  because  it  was  difficult  to  as- 
certain whether  he  counted  from  the  first  symptoms  or  from 
the  time  when  he  took  to  his  bed,  and  because  the  stage  of  the 
rash  often  indicated  a  probable  duration  which  did  not  corre- 
spond with  the  patient's  story. 

The  temperatures  were  all  taken  by  rectum  by  the  nurses 
and  are,  therefore,  reliable. 

Analysis  of  the  charts  shows  that  few  patients  were  ill  in  the 
ward  for  more  than  four  or  five  days  before  the  temperature 
began  to  fall,  showing  that  few  were  seen  in  the  early  stages. 

The  mean  temperature  before  it  began  to  fall  varied  in  dif- 
ferent cases  from  102°  to  105°;  the  greatest  number  having 
fever  of  103.5°  to  104°. 

The  daily  fluctuations  of  the  temperature  during  the  period 
of  high  fever  amounted,  generally,  to  about  one  degree,  and 


TYPHUS  IN  SERBIA  117 

seldom  to  more  than  two  degrees.  They  were  characterized  by 
morning  remissions  and  evening  exacerbations,  and  this  se- 
quence was  rarely  disturbed. 

The  defervescence  was  nearly  always  by  lysis  with  marked 
morning  remissions.  The  duration  of  the  lysis  in  different 
cases  varied  considerably. 

Out  of  twenty  charts  in  which  the  defervescence  proceeded 
without  interruption  only  two  show  the  temperature  dropping 
to  normal  within  twelve  hours.  In  four  the  lysis  was  rapid,  last- 
ing in  two  cases  for  two  days,  and  in  two  other  cases  for  three 
days.  It  lasted  four  days  in  five  cases,  five  days  in  four  cases,  six 
days  in  three  cases,  seven  days  in  one  case,  and  eight  days  in 
one  case.  The  proportion  of  cases  with  fever  terminating  by 
crisis  in  twelve  hours  was  considerably  smaller  than  these 
figures  indicate.  In  fact,  it  was  so  unusual  as  to  excite  con- 
siderable interest. 

It  has  usually  been  stated  by  the  older  authors  that  typhus 
fever  terminates  ordinarily  by  crisis,  but  many  have  since 
denied  that  this  is  the  case.  The  dispute  results  largely  from 
using  the  term  crisis  in  different  senses.  To  some  of  the  older 
writers  it  signified  a  rapid  improvement  in  the  patient's  con- 
dition, "  Si  change  so  definite  that  one  might  name  the  day  or 
even  the  hour  when  it  began  ";  to  others  it  signified  a  rapid  fall 
of  temperature  as  compared  with  the  gradual  descent  in  ty- 
phoid; and  to  this  generation,  more  familiar  with  lobar  pneu- 
monia than  with  typhus,  the  word  crisis  has  come  to  signify 
a  precipitate  drop  of  temperature  from  the  original  high  level 
to  normal  or  lower  within  less  than  twenty-four  hours. 

Two  charts  reproduced  by  Murchison  ^  show  gradual  de- 
scent of  the  fever,  and  two  others  rapid  descent,  the  shortest 
period  of  defervescence,  however,  being  three  days.  That  is  to 
say,  the  fever  in  all  these  cases  ended  by  lysis. 

He  says  of  the  temperature:  ''After  attaining  its  maximum 
there  may  be  little  change  for  several  days,  but  some  time  be- 
tween the  seventh  and  tenth  day,  except  in  severe  cases,  there  is 
usually  a  slight  remission,  and  then  the  temperature  gradually 

1  Murchison :  loc.  cit. 


118  CLINICAL  OBSERVATIONS 

falls  until  about  the  fourteenth  day,  when  it  rapidly  subsides 
to  about  the  normal  standard.  In  a  single  night  it  may  fall 
from  four  to  six  degrees,  but  when  there  is  pulmonary  conges- 
tion, the  fall  is  slower.  Occasionally  an  elevation  of  two  or  more 
degrees  precedes  the  final  fall,  and  then  a  brief  fall  of  moderate 
amount  may  intervene  between  the  final  rise  and  the  rapid 
descent.  This  sudden  fall  of  temperature  about  the  fourteenth 
day  is  peculiar  to  typhus  and  may  be  useful  in  diagnosis.  Be- 
fore attaining  its  maximum  the  daily  variations  of  tempera- 
ture are  slight,  but  during  the  second  week  they  may  amount  to 
two  degrees,  the  maximum  being  usually,  but  not  always,  in  the 
evening." 

Curschmann,^  figures  a  series  of  charts  which  illustrate  the 
points  made  by  Murchison.^  They  show  also  great  variations 
in  the  length  of  defervescence. 

As  compared  with  typhoid,  typhus  shows  a  marked  tend- 
ency to  rapid  defervescence,  but  with  lobar  pneumonia  as  the 
standard,  the  reverse  is  true. 

Murchison  ^  says  that  a  remission  is  to  be  expected  about  the 
seventh  day;  and  Curschmann  ^  observed  remissions  in  some 
cases  a  few  days  before  the  beginning  of  the  final  defervescence. 

None  of  my  charts  show  this  remission  distinctly,  but  in 
some  of  them  a  secondary  rise  of  temperature  gives  the  appear- 
ance of  an  intercurrent  relapse  such  as  occurs  in  typhoid. 
Relapse  is  believed  to  occur  in  typhus  fever  extremely  rarely, 
if  at  all.  The  secondary  rises  in  my  cases  might  be  accounted 
for  by  complications. 

Sweating,  more  or  less  profuse,  was  not  infrequently  asso- 
ciated with  fall  of  temperature. 

11.    The  Skin 

The  Eruption,  according  to  Murchison,^  generally  appears 
on  the  fourth  or  fifth  day. 

In  the  few  early  cases  that  I  saw,  a  scanty,  pink,  maculo- 
papular  rash  was  first  discovered  about  the  clavicles  and  on  the 

1  Curschmann:  loc.  cit.  ^  Curschmann:  loc.  cit. 

2  Murchison:  loc.  cit.  *  Murchison:  loc.  cit. 


TYPHUS  IN  SERBIA  119 

shoulders.  On  the  succeeding  day  it  was  always  widespread, 
and  could  be  found  more  or  less  abundantly  on  the  trunk, 
arms,  legs,  the  backs  of  the  hands  and  feet,  and  often  on  the 
palms  and  soles.  It  seemed  to  have  no  preference  for  flexor  or 
extensor  surfaces,  it  did  not  spread  progressively,  nor  did  it 
appear  at  intervals  in  crops,  but  it  often  became  more  abund- 
ant on  the  third  day  than  it  had  been  on  the  second. 

Careful  examination  of  the  mouth  and  pharynx  failed  to 
show  a  definite  eruption,  but  in  a  few  cases  several  spots  of 
doubtful  significance  were  seen. 

On  the  forehead  near  the  edge  of  the  hair,  and  on  the  scalp  in 
several  cases  lesions  were  found  which  might  either  have  be- 
longed to  the  eruption  or  have  been  due  to  other  causes.  I  saw 
not  a  single  patient  with  a  definite  rash  on  the  face,  nor  do  I 
believe  that  any  such  occurred  in  the  Lady  Paget  Hospital 
while  I  was  there.  Dr.  Sellards,  however,  told  me  that  he  saw  a 
pronounced  eruption  on  the  face  in  a  fair-skinned  patient  in 
Belgrade,  and  that  in  this  case  the  character  of  the  lesions  was 
the  same  on  the  face  as  on  the  body. 

In  the  earliest  stage  the  rash  was  rose  pink,  not  dirty  pink  as 
described  by  some  authors.  Subsequently  its  color  changed  to 
red,  then  to  purple  in  some  cases  and  to  rusty  red  in  others. 
Before  disappearing  the  remnants  turned  to  a  faded,  dirty 
brown  color.  Most  of  the  spots  faded  without  leaving  any  pig- 
ment behind,  whereas  others,  the  darker  ones,  and  especially 
those  on  the  wrists,  ankles,  and  backs  of  the  hands,  showed 
purple  or  brown  haemorrhagic  pigment,  which  persisted  for  a 
considerable  number  of  days. 

The  remnants  of  the  rash  are  rather  characteristic  but  diffi- 
cult to  recognize  with  certainty  when  first  seen  at  this  stage, 
and  particularly  so  when,  as  is  often  the  case,  the  patient's 
body  is  sprinkled  with  minute  ecchymoses  resulting  from  flea 
bites.  These  ecchymoses  differ  as  described  below  from  typical 
typhus  spots.  Nevertheless,  on  the  ground  of  this  possible 
error,  I  have  excluded  from  the  list  of  undoubted  typhus  cases 
a  considerable  number  that  first  came  under  observation  at  a 
late  stage. 


120  CLINICAL  OBSERVATIONS 

The  change  in  color  of  the  rash  seems  to  be  due  to  two 
causes:  firstly,  to  increasing  hyperaemia  often  followed  by 
lividity,  and  secondly,  to  the  deposit  of  brownish  pigment. 
The  amount  of  pigment  was  greater  in  the  larger,  elevated 
spots  than  in  the  smaller  ones  or  in  the  macules.  It  seemed  to 
be  proportional  to  the  degree  of  local  congestion. 

In  the  pink  stage  the  color  of  the  spots  completely  disap- 
peared on  pressure,  in  the  red  stage  most  of  it  disappeared 
leaving  a  faint  rusty  tinge,  but  in  the  cases  in  which  the  erup- 
tion became  livid,  pressure  had  little  influence  on  the  color  of 
the  lesions. 

The  spots  did  not  all  change  color  at  the  same  time  or  in  the 
same  way.  When  the  eruption  was  abundant,  large  pale  pink, 
smaller  rose  pink,  rusty  red,  and  purple  spots  might  be  mixed 
together,  and  the  predominance  of  one  or  another  variety 
determined  the  general  color. 

'^Subcuticular  mottling"  or  ''marbling"  of  the  skin  has 
been  found  by  many  observers  associated  with  the  spots  and 
has  been  considered  by  them  to  be  a  part  of  the  typhus  erup- 
tion. It  is  clearly  shown  in  the  colored  illustrations  of  Murchi- 
son,^  Jenner,^  and  Curschmann.^ 

In  a  few  of  my  cases  vague,  pale  pink  blotches  were  ob- 
served among  the  brighter  spots  at  an  early  stage  of  the  erup- 
tion, but  they  did  not  give  a  definite  marble-like  effect.  In 
other  instances  the  rash  was  so  profuse  that  mottling  could  not 
have  been  readily  distinguished  if  present.  In  the  majority  of 
the  cases  "subcuticular  mottling"  was  looked  for  in  vain,  but 
in  the  case  of  Series  No.  61,  when  the  eruption  was  in  an  early 
stage  and  spots  not  very  numerous,  much  pink  mottling  and 
blotches  of  irregular  outline  were  observed,  and  in  the  case  of 
Autopsy  No.  25,  a  peculiar  mottling  was  noted  on  the  front  of 
the  chest  during  life. 

Not  infrequently,  in  the  period  of  nervous  depression,  the 
limbs  showed  large,  bluish,  marble-like  markings.  They  were 
associated  with  duskiness  of  the  skin  and  resembled  ordinary 
cutis  mormorata.    Probably  they  had  nothing  to  do  with  the 

1  Murchison:  loc.  cit.  ^  Jenner:  loc.  cit.  ^  Curschmann:  loc.  cit. 


TYPHUS  IN  SERBIA  121 

eruption  but  should  be  regarded  as  local  circulatory  phe- 
nomena. 

The  typhus  eruption  is  notoriously  variable  in  appearance. 
The  pictures  of  Jenner,^  Murchison,^  and  Curschmann  ^  show 
many  differences  in  detail. 

The  eruption  in  our  cases  was  so  carefully  examined  that 
typical  marbling  could  scarcely  have  been  overlooked  had  it 
been  visible  when  they  arrived,  but  the  dark  skins  of  many  of 
our  patients  may  have  rendered  it  invisible.  Moreover,  it 
seems  probable  that  mottling  or  marbling  is  most  distinct  in  the 
early  stages  of  the  eruption  and  may  even  disappear  altogether 
after  a  few  days.  If  this  be  so,  failure  to  find  it  in  more  of  our 
cases  can  be  explained  on  the  ground  that  most  of  them  were 
not  seen  by  us  until  the  later  stages  indicated  by  the  purple 
phase  of  the  rash. 

The  spots  of  the  eruption  were  macular  or  papular  and  were 
very  slightly  elevated.  Generally,  there  were  both  macules  and 
papules,  the  latter  having  irregular,  ill-defined  margins.  Some- 
times they  were  confluent,  often  they  were  very  close  together. 
When  discrete  they  were  roughly  circular  in  shape.  They  varied 
in  size  from  about  one  to  three  or  four  mm.  in  diameter.  The 
variation  was  always  considerable  in  the  individual  case,  but  in 
some  patients  the  larger,  and  in  others  the  smaller,  lesions  pre- 
dominated. In  profuse  eruptions  the  larger  type  generally 
prevailed. 

Dr.  Smith  showed  me  a  patient  in  the  early  eruptive  stage 
whose  skin  was  almost  as  dark  as  that  of  the  average  negro. 
There  was  a  profuse  crop  of  small  papular  lesions  clearly  visible 
on  account  of  their  elevation  but  scarcely  perceptible  by  their 
color.  Papules  were  easily  detected  in  many  cases  by  palpation 
when  the  elevation  was  almost  imperceptible  to  the  eye. 

Murchison  ^  and  Jenner  ^  say  that  the  rash  is  elevated  only  at 
first.  This  rule  was  not  invariably  true  in  my  cases.  On  the 
contrary  the  larger  and  darker  papules  often  remained  ele- 
vated until  the  later  stage  when  they  had  become  haemor- 
rhagic. 

^  Jenner:  loc.  cit.  ^  Murchison:  loc.  cit.  ^  Curschmann:  loc.  cit. 


122  CLINICAL  OBSERVATIONS 

There  seems  to  be  a  certain  amount  of  confusion  as  to  what  is 
meant  by  the  terms  '^petechial"  and  ^^ mulberry  rash." 

Murchison  ^  quotes  Wilson-  as  follows:  ''When  the  san- 
guineous spots  (of  purpura)  are  minute  they  are  termed  pe- 
techiae,''  and  it  would  seem,  therefore,  that  this  word  should  be 
used  to  signify  small  haemorrhagic  spots  like  those  of  purpura. 
Keating's  dictionary,^  on  the  other  hand,  says  under  the  head 
of  petechiae:  ''It.  petechio,  '  flea  bite.'  Small  reddish  spots  on 
the  skin  like  flea  bites. ^^  Apparently  the  term  has  been  used 
variously  by  different  authors,  but  it  is  as  good  as  any  we  have 
to  describe  the  small  haemorrhagic  spots  so  common  in  tj^phus. 

In  typical  cases  the  typhus  eruption  shows  differences  from 
purpura  which  should  be  emphasized.  The  spots  of  purpura 
are  haemorrhagic  from  the  beginning  and  sharply  defined, 
whereas  those  of  typhus  are  neither. 

The  fresh  flea  bite  is  distinguishable  from  the  pink  maculo- 
papule  of  the  early  eruption  by  the  haemorrhagic  point  in  its 
center.  The  old  flea  bite  difl:"ers  from  the  petechial  typhus 
macule  in  being  of  a  brighter  red  color,  more  circular  in  shape, 
and  in  having  a  more  sharply  defined  outline.  Flea  bites  are 
more  uniform  in  size,  and  are  distributed  chiefly  on  the  body 
but  typhus  spots  in  the  last  stage  generally  show  best  on  the 
wrists,  ankles,  and  on  the  backs  of  hands  or  feet.  Flea  bites, 
however,  may  be  so  numerous  on  the  body  and  limbs  as 
strongly  to  suggest  a  typhus  eruption  and  the  fact  that,  in 
some  cases,  the  typhus  rash  consists  chiefly  of  small  spots, 
leaves  an  opening  for  error.  I  saw  two  cases  sent  to  the  hos- 
pital with  the  diagnosis  of  typhus  in  which  enormous  numbers 
of  flea  bites  were  scattered  all  over  the  body  and  limbs.  One  of 
the  patients  probably  did  not  have  typhus,  and  in  the  other 
case,  the  diagnosis  remained  in  doubt  owing  to  the  difficulty  of 
distinguishing  the  eruption  among  the  bites. 

The  term  "mulberry  rash"  was  first  used  by  Jenner  ^  who 
says  that  "the  spots"  .  .  .  "have  a  dusky,  pinkish-red  color, 

1  Murchison:  loc.  cit. 

2  Wilson:  Dis.  of  the  Skin,  3d  ed.,  1851,  p.  337. 

3  Keating:  Diet,  of  Med.,  Phil.,  1892. 
*  Jenner:  loc.  cit. 


TYPHUS  IN  SERBIA  123 

somewhat  like  the  stains  of  mulberry  juice."  The  term  there- 
fore serves  to  describe  cases  of  profuse  eruption  in  the  later 
stages. 

Hyperaemia.  Coincident  with  the  appearance  of  the  rash, 
and  perhaps  earlier,  there  was  a  hyperaemic  flush  which  was 
most  pronounced  over  the  malar  prominences  and  on  the  ears. 
Later,  the  ears  became  bluish  red,  and  the  color  in  the  malar 
region  dull  red.  This  coloring  was  peculiar  and  rather  char- 
acteristic. It  was  considerably  darker  than  the  ordinary  flush 
of  fever,  less  sharply  circumscribed,  and  less  transitory.  It 
often  persisted  well  into  the  convalescent  period. 

Sometimes  the  hyperaemia  extended  mask-like  across  the 
nose  and  cheeks  and  up  to  the  eyes,  and  a  separate  patch  was 
seen  over  the  end  of  the  chin.  In  other  cases,  and  particularly 
in  t^e  early  stages  of  the  rash,  the  entire  face  and  neck  were 
hyperaemic,  and  the  redness  often  extended  in  a  V-shape  on  to 
the  upper  part  of  the  sternum.  It  showed  a  pronounced  tend- 
ency to  be  Hmited  to  the  parts  which  had  been  exposed  to  the 
sun,  but  in  a  few  instances  it  was  found  also  on  the  front  of  the 
chest  and  shoulders.  In  one  case  it  covered  the  greater  part  of 
the  trunk. 

In  the  later  stages  of  fever,  the  flush  which  had  been  due  to 
active  hyperaemia  was  replaced  by  congestion  with  cyanosis, 
or  by  a  leaden  hue,  in  those  about  to  die.  In  other  cases  the 
malar  flush  persisted  but  the  ears  became  cyanotic  and  the 
rest  of  the  face  assumed  a  muddy  tint  with  underlying  pallor. 

Pigmentation.  Repeatedly  the  face  was  observed  to  be 
decidedly  browner  in  convalescence  than  it  had  been  at  the 
time  of  admission  to  the  hospital.  This  was  noted  not  only  in 
those  skins  which  had  been  darkened  by  exposure,  but  also  in 
several  patients  having  Kght  complexions.  It  seems  probable 
that  the  intense  hyperaemia  and  prolonged  congestion  left 
behind  some  pigmentation  analogous  to  that  following  expo- 
sure to  the  sun.  The  writer  has  found  in  the  literature  no 
mention  of  such  an  increase  of  pigmentation. 

The  Taches  Bleudtres  were  looked  for  but  not  found.  Failure 
to  find  them  may  have  been  due  to  the  rather  dark  skins  of  most 


124  CLINICAL  OBSERVATIONS 

of  our  patients.  Not  only  were  their  skins  originally  dark  in 
most  cases,  but  a  multitude  of  bites  and  scratchings  had  added 
to  the  pigmentation. 

When  there  was  more  or  less  acne  intermingled  with  an 
eruption  and  a  multitude  of  bites  the  picture  was  confusing. 

Purpuric  Spots  were  found  singly  in  a  few  cases  beneath  the 
finger  nails  or  on  the  pads  of  the  fingers  during  convalescence. 
One  of  the  latter  developed  into  a  small  pustule. 

Sudamina  were  frequently  observed  about  the  neck  and 
shoulders. 

Yellowness  of  the  palms  of  the  hands  was  noted  in  two  cases 
late  in  the  disease. 

Herpes  was  observed  repeatedly,  most  often  on  the  ears, 
several  times  about  the  nose  or  lips,  and  occasionally  on  other 
parts  of  the  face. 

III.    Circulatory  Signs  and  Symptoms 

Heart  Rate  and  Pulse  Rate.  The  pulse  rate  corresponded  with 
that  of  the  heart  except  when  the  pulse  was  extremely  weak. 
In  the  case  of  Autopsy  No.  23  on  the  last  day  of  life  such  a  dis- 
crepancy occurred. 

In  the  first  half  of  the  febrile  period  the  pulse  rate  was  low, 
as  a  rule,  in  proportion  to  the  temperature.  It  ranged  most 
often  between  the  upper  eighties  and  one  hundred  or  slightly 
higher  with  temperatures  of  103°  to  104°.  Sometimes  the  pulse 
rate  remained  low  throughout  the  illness  (Series  No.  48).  In 
other  cases,  particularly  in  the  sicker  patients,  the  rate  in- 
creased gradually  to  120  (Series  No.  59)  or  higher.  Most  of  the 
patients  whose  pulse  rate  went  above  130  died.  Rates  between 
140  and  148  were  counted,  however,  in  a  few  patients  who 
recovered  (Series  Nos.  9  and  93).  The  pulse  often  foUowed  the 
temperature  closely  (Series  Nos.  9,  61,  and  93).  In  fatal  cases 
with  a  terminal  rise  of  temperature  the  pulse  usually  followed 
the  temperature  (Autopsy  Nos.  18  and  25).  Two  patients  dy- 
ing with  moderate  fever  had  pulse  rates  that  were  relatively  high 
(Autopsy  Nos.  23  and  24)  on  the  last  days. 

An  old  man  who  died  suddenly  and  unexpectedly  with  a 


TYPHUS  IN  SERBIA  125 

temperature  of  102.5°  had  a  pulse  rate  of  only  108.  The  au- 
topsy showed  a  dilated  heart  with  brownish,  soft  myocardium. 
The  myocardial  change  was  believed  to  be  due  in  large  measure 
to  chronic  degeneration  (Autopsy  No.  20). 

With  the  decline  of  the  fever,  except  in  fatal  cases,  the  pulse 
became  slower.  Frequently,  after  several  days  or  a  week  of 
normal  or  subnormal  temperature,  there  was  a  bradycardia 
with  rates  between  44  and  64,  which  lasted  for  three  or  four 
days.     (Series  Nos.  10  and  57.) 

The  bradycardia  in  Series  No.  57  cannot  be  attributed  to 
digitalis  because  the  patient  received  none.  In  Series  No.  10 
digitalis  was  used,  but  was  omitted  two  days  before  the  pulse 
rate  reached  its  lowest  point.  The  digitalis  may  have  caused  it 
in  this  case.  It  almost  certainly  did  so  in  the  case  of  Series  No. 
83,  in  which  heart-block  seems  to  have  developed. 

Jenner  ^  observed  that  the  bradycardia  following  fever  was 
brought  about  by  lengthening  of  the  diastolic  pause  and  with- 
out change  in  the  first  sound,  but  that  bradycardia  due  to 
cerebral  conditions  was  characterized  by  a  lengthened  first 
sound  and  normal  diastolic  pause. 

The  disproportionate  slowness  of  the  pulse  in  relation  to 
temperature,  so  common  in  tjrphoid  fever,  was  not  marked  in 
my  typhus  cases.  It  was  seen  most  often  in  the  earlier  stages  of 
the  illness.  It  seldom  persisted  until  the  beginning  of  defer- 
vescence. 

Rhythm.  With  the  exception  of  the  supposed  case  of  digitalis 
block  mentioned  under  bradycardia,  pronounced  changes  in  the 
cardiac  rhythm  were  not  observed. 

In  most  of  the  cases,  however,  in  which  the  pulse  became 
very  weak  it  was  found  to  be  markedly  irregular  in  force  and 
slightly  so  in  rhythm.  A  corresponding  slight  irregularity  was 
noted  in  the  heart's  action. 

Murchison  ^  shows  a  series  of  sphygmographic  tracings  of 
the  pulse  after  Sanderson.  Murchison's  Figure  6  corresponds 
to  the  bounding  type  of  pulse.  His  Figure  7,  which  he  calls 
"the  irregular  pulse  of  irritative  fever,"  corresponds  to  that 

1  Jenner:  loc.  cit.  ^  Murchison:  loc.  cit. 


126  '  CLINICAL  OBSERVATIONS 

above  described  as  being  irregular  in  force  and  rhythm,  and 
Figure  8,  which  he  called  the  ''irregular  undulatory  pulse  of 
advanced  typhus,"  depicts  the  small,  weak  or  ''thready"  type 
of  pulse.  Measurement  of  this  last  tracing  shows  no  variation 
in  rate  but  shght  differences  in  size  of  the  waves.  These  varia- 
tions seem  to  indicate  fluctuations  in  pressure. 

In  his  chapter  on  acute  febrile  affections  of  the  heart  (on  p. 
280,  Figs.  169  and  170),  Mackenzie  ^  gives  illustrative  tracings 
of  a  type  of  irregularity  which  he  attributed  to  failure  of  con- 
tractility. He  says  that  he  found  this  kind  of  arrhythmia  in  all 
his  fatal  cases  of  pneumonia.  Murchison's  ""  Figure  7  probably 
illustrates  the  same  condition. 

Mackenzie's  ^  Figure  176,  p.  286,  shows  a  rapid  pulse  which 
is  irregular  in  force  but  httle,  if  at  all,  in  rhythm.  This  type  of 
pulse,  he  says,  is  "usually  associated  with  greatly  relaxed  ar- 
teries, and  a  sphygmogram  shows  little  or  no  sign  of  a  dicrotic 
wave,  indicating  great  lowering  of  the  pressure  during  diastole 
of  the  heart."  "  Figures  172-176  show  the  characteristic  fea- 
tures of  the  pulse  in  acute  fatal  pneumonia  in  a  young,  pre- 
viously strong  and  healthy  child." 

Apparently,  Mackenzie  beheved  that  the  tracings  on  pp. 
280  and  286  of  his  book  represent  varieties  of  arrhythmia  due  to 
the  same  cause,  namely,  to  failure  of  contractiUty. 

Hay  ^  also  figures  an  irregularity  of  force,  without  change  in 
rhythm  (Fig.  119,  p.  158  of  his  book),  which  he  says  is  found  in 
"pneumonia,  pericarditis,  septic  and  other  conditions,  and  in- 
dicates a  grave  prognosis." 

The  existence  of  irregularity  in  force  of  beats  was  strikingly 
demonstrated  in  the  case  of  Series  No.  10  on  April  28  when,  on 
taking  the  blood-pressure  by  auscultation  under  the  cuff,  some 
beats  registered  90,  others  70,  and  still  others  were  not  heard  at 
all.    (See  also  Series  No.  9.) 

Premature  systoles  were  heard  occasionally  in  Series  No.  92. 

Heart  Sounds.  The  commonest  abnormality  was  faintness, 
shortening,  or  blurring  of  the  first  sound.  This  was  observed  in 

1  Mackenzie:  Diseases  of  the  Heart,  3d  ed.,  Lond.,  1913.        2  Murchison:  loc.  cit. 
*  Hay:  Graphic  Methods  in  Heart  Disease,  Lond.,  1909. 


TYPHUS  IN  SERBIA  127 

practically  every  case,  and  was  generally  the  earliest  change  to 
develop  and  the  last  to  disappear. 

In  most  cases  the  second  sound  in  the  aortic  area  was  di- 
minished, but,  at  the  same  time,  that  at  the  apex  might  be 
accentuated.  With  the  diminution  in  the  second  sound  in  the 
aortic  area  that  in  the  pulmonic  area  became  relatively  louder. 
Sometimes  it  was  definitely  accentuated. 

Normally  loud,  or  even  accentuated  heart  sounds  sometimes 
accompanied  a  small  weak  pulse,  suggesting  that  the  circula- 
tory deficiency  was  to  be  attributed  to  loss  of  tone  of  the  vascu- 
lar system  rather  than  to  weakness  of  the  heart.  (Autopsy  No. 
24,  June  16.) 

It  has  long  been  believed  that  vascular  dilatation  may  cause 
circulatory  weakness  in  typhoid  fever.  William  Stokes  ^  in 
1854  devoted  a  chapter  to  the  heart  in  'Hyphus  fever."  In  the 
summary  (par.  33)  he  says:  ''In  certain  cases  of  the  worst 
maculated  typhus  an  excited  state  of  the  heart  may  exist 
throughout  the  disease,  although  the  pulse  be  feeble  and  the 
extremities  cold."   This  points  to  vascular  dilatation. 

His  observations  on  the  heart  in  fever  are  careful  and  in- 
teresting, but  lose  some  of  their  value  from  the  fact  that,  al- 
though recognizing  symptomatic  differences  between  typhoid, 
typhus,  and  relapsing  fevers,  he  believed  them  to  be  varieties  of 
the  same  disease,  and  did  not  always  make  it  clear  of  which  he 
was  speaking. 

Stokes  seems  not  to  have  appreciated  the  interrelation  of 
cardiac  action  and  vascular  tone. 

Ortner  ^  made  an  important  contribution  to  this  subject  in  a 
study  of  typhoid  fever  in  1904.  He  states  that  ''stronger" 
cardiac  action  may  compensate  for  diminished  vascular  tone, 
and  thus  maintain  the  normal  blood-pressure. 

The  case  of  Series  No.  9  illustrates  accentuated  heart  sounds 
^nd  small  weak  pulse  followed  on  the  next  day  by  heart  sounds 
of  poor  quality  and  a  weaker  pulse.  Prompt  improvement  after 
an  infusion  of  salt  solution  in  this  case  points  to  the  conclusion 

1  Stokes:  loc.  cit. 

2  Ortner:  Verhandl.  d.  Cong.  f.  inn.  Med.,  1904,  xxi,  255. 


128  CLINICAL  OBSERVATIONS     ^ 

that  the  vessels  were  mainly  at  fault,  but  a  subsequent  infusion 
brought  out  presumptive  signs  of  cardiac  weakness  also. 

In  the  case  of  Series  No.  10  the  heart  sounds  were  never 
good  while  the  patient  was  under  observation,  the  pulse  was 
always  irregular  in  force,  and  heart  dulness  to  the  right  be- 
came increased.  When  drugs  failed  to  act  salt  solution  was 
tried,  but  without  much  benefit.  The  second  infusion  was  dis- 
continued after  a  small  quantity  had  been  given  because  the 
heart  failed  to  respond  satisfactorily.  In  this  case,  whether  or 
not  there  was  vascular  relaxation,  the  heart  itself  presumably 
was  weak.  These  facts  point  to  myocardial  as  well  as  to  vascu- 
lar disturbances  and  perhaps  to  diminution  of  contractility  as 
suggested  above. 

Murmurs,  systolic  in  time,  were  heard  in  many  cases.  Gen- 
erally they  were  loudest  in  the  pulmonic  area  and  were  not 
transmitted  to  the  axilla.  They  were  believed  to  be  of  func- 
tional origin. 

Dilatation  of  the  heart,  evidenced  by  increase  of  dulness,  was 
observed  in  the  case  of  Series  No.  10  only.  At  autopsy  dilata- 
tion of  the  whole  heart  was  found  occasionally,  but  dilatation  of 
the  right  ventricle  alone  was  more  common.  In  other  cases 
there  was  no  dilatation,  and  sometimes  the  heart  was  firmly 
contracted. 

The  Pulse  was  often  of  the  bounding  type  particularly  in  the 
earUer  part  of  the  illness.  Later  it  became  small  and  softer. 
In  the  severer  cases  it  was  small  and  weak  or  "thready"  when 
rapid.  Occasionally,  when  it  had  been  holding  up  well  under 
digitahs,  it  would  suddenly  go  to  pieces,  and  the  patient  would 
seem  to  be  in  an  alarming  condition.  After  an  injection  of 
strychnin,  of  camphor,  or  of  ether,  however,  it  often  improved 
promptly.  This  occurred  once  before  anything  had  been  ad- 
ministered, so  that  it  is  doubtful  what  would  have  happened  in 
the  other  instances  had  nothing  been  done.  Whether  the  phe- 
nomenon was  of  cardiac  or  vascular  origin  is  uncertain.  In  the 
case  of  Autopsy  No.  24  this  condition  recurred  repeatedly. 

There  were  other  cases  in  which  the  pulse  became  weaker 
gradually,  and  several  of  these  responded  well  to  intravenous 


TYPHUS  IN  SERBIA  129 

saline  infusions.  Sometimes  the  infusion  had  to  be  repeated 
in  from  12  to  24  hours.  It  was  used  most  often  when  alarming 
weakness  of  the  pulse  persisted  for  some  hours  in  spite  of  other 
stimulants.  When  there  were  signs  of  deficient  ingestion  of 
fluid,  or  after  persistent  diarrhoea,  infusions  were  also  used. 

Pulses  of  poor  quality  often  improved  after  the  morning  care 
and  feeding,  remained  pretty  satisfactory  through  the  day,  and 
weakened  again  in  the  evening.  The  nurses  frequently  re- 
ported cases  in  which  death  seemed  imminent  during  the  night 
although  the  condition  during  the  day  had  been  relatively 
good.  They  used  hot  drinks,  strychnin,  and  camphor  freely.  1 
was  often  surprised  in  the  morning  to  find  patients  still  alive 
whose  condition  the  evening  before  had  been  anything  but 
encouraging. 

In  the  case  of  Series  No.  21,  in  which  pulmonary  symptoms 
were  prominent,  the  pulse  was  notably  good  until  and  even 
after  the  death  agony  began.     There  was  no  autopsy. 

Dicrotism,  so  common  in  typhoid  fever,  was  looked  for  in  all 
my  cases,  but  was  never  found  fully  developed.  Curschmann  ^ 
says  that  it  is  rare  in  typhus. 

Blood-pressure  readings  both  systolic  and  diastolic  were 
taken  in  most  cases  with  the  stethoscope  below  the  cuff  of  the 
sphygmomanometer.  The  systolic  pressure  showed  a  tendency 
to  fall  gradually  during  the  course  of  the  disease.  It  was  more 
or  less  reduced  in  practically  every  instance.  It  varied  be- 
tween the  extreme  limits  of  75  and  125,  but  lay  most  often 
between  95  and  110  mm.  of  mercury.  In  convalescence  it 
worked  up  again  gradually. 

The  diastolic  pressure  level  was  generally  between  65  and  75. 
The  limits  of  difference  were  30  and  85.  Sometimes  there  was  a 
marked  reduction  in  diastolic  pressure  associated  with  a  bound- 
ing pulse.  (Series  Nos.  1  and  49.)  In  the  case  of  Series  No.  49 
the  diastolic  pressure  soon  rose  again,  but  in  Series  Nos.  1  and 
59  it  remained  low  while  the  high  fever  lasted.  More  often  the 
diastolic  pressure  was  approximately  proportional  to  the 
systohc  pressure,  i.e.,  equal  to  about  three-quarters  of  it. 

^  Curschmann:  loc.  cit.    , 


130  CLINICAL  OBSERVATIONS 

The  case  of  Autopsy  No.  24  showed  a  falhng  systolic  and  a 
rising  diastolic  pressure. 

The  pulse  pressure  in  general  showed  a  gradual  fall  until  the 
beginning  of  convalescence.  With  the  bounding  type  of  pulse 
it  was  large.  In  the  case  of  Series  No.  59  it  dropped  from  80  to 
50  with  a  drop  in  systolic  pressure  from  125  to  95.  During  this 
time  the  patient's  condition  was  becoming  progressively  worse^ 
but  his  pulse  remained  relatively  good  in  volume.  The  reverse 
order  took  place  in  the  case  of  Series  No.  49.  In  this  case,  with 
a  falling  temperature  and  general  improvement,  the  diastolic 
pressure  rose  from  50  to  70,  and  the  systolic  only  from  105  to 
110,  so  that  again  the  pulse  pressure  was  reduced.  More  com- 
monly, in  convalescence,  the  pulse  pressure  was  increased  by  a 
gradual  and  marked  rise  in  systolic  and  little  change  in  the 
diastolic  pressure.     (Series  No.  1.) 

Several  times  in  the  later  stages  of  the  illness  the  Corrigan 
type  of  pulse  was  noted.  In  a  case  in  which  this  was  observed 
the  blood-pressure  was  recorded  at  that  time  as  90  S-40  D. 
No  diastolic  murmur  was  heard.  In  the  case  referred  to  under 
Autopsy  No.  5  with  a  similar  pulse  a  diastolic  murniur  was 
heard,  but  at  autopsy  no  lesion  of  the  valve  was  found  to  ex- 
plain it. 

Such  murmurs  have  been  explained  on  the  basis  of  failure  of 
the  aortic  ring  to  contract,  and  a  resulting  relative  insufficiency 
of  the  aortic  value. 

Ortner  ^  reported  such  a  condition  in  a  case  of  typhoid  fever. 

Summary 

CUnical  evidence,  therefore,  points  to  the  existence  of  myo- 
cardial as  well  as  vascular  disturbances  in  typhus. 

A  similar  conclusion  was  reached  by  Ortner  ^  in  regard  to 
typhoid  fever. 

Myocardial  weakness  appears  to  be  decidedly  more  fre- 
quent, however,  in  typhus  than  in  typhoid  fever. 

1  Ortner:  loc.  cit. 


TYPHUS  IN  SERBIA  131 

IV.   Pathology  of  the  Circulatory  System 

The  heart  in  our  series  of  twenty  autopsy  cases  presented  a 
variety  of  conditions  ranging  from  softness  to  firmness  of  the 
muscle,  and  from  a  state  of  general  contraction  to  one  of  general 
dilatation  of  the  chambers.  '  The  intermediate  condition  was 
represented  by  hearts  in  which  the  left  ventricle  was  con- 
tracted and  the  right  ventricle  dilated  or  relaxed.  Firmness  of 
the  muscle  and  contraction  of  the  cavities  generally  went  to- 
gether, but  in  some  of  the  contracted  hearts  the  muscle  was 
soft.  It  was  soft,  also,  in  all  the  dilated  hearts,  and  in  some  of 
these  it  was  pale  in  color. 

Engorgement  of  the  great  vessels  with  blood  was  noted 
specifically  in  two  cases  in  which  the  heart  was  soft,  and  in  two 
in  which  it  was  contracted.  Probably  there  was  engorgement 
also  in  other  cases  in  which  it  was  not  specifically  noted.  This 
engorgement  seems  not  to  have  borne  a  definite  relation  either 
to  softness  or  to  dilatation  of  the  heart. 

Marked  passive  congestion  of  the  lungs  was  found  in  eleven 
cases,  but  dilatation  of  the  whole  heart  or  of  the  right  ventricle 
alone  was  observed  in  only  six  cases.  In  other  words,  passive 
congestion  of  the  lungs  bore  no  obvious  relation  to  dilatation 
of  the  heart. 

Of  the  cases  with  dilated  hearts  one  died  in  the  period  of  ner- 
vous depression,  one  during  defervescence  or  later,  and  one  in 
the  postfebrile  period. 

Of  the  three  cases  with  dilated  right  ventricles  one  died 
at  the  end  of  the  period  of  nervous  excitement,  one  in  the 
postfebrile  period,  and  one  at  an  intermediate  stage  of  the 
disease. 

The  two  patients  that  showed  merely  relaxation  of  the  right 
ventricle  without  dilatation  died  in  the  postfebrile  period. 

The  cases  permit  of  no  deductions  as  to  the  frequency  of 
cardiac  dilatation  in  the  stage  of  nervous  excitement  because 
there  was  only  one  death  at  that  stage  but,  of  the  six  cases 
above  mentioned  in  which  more  or  less  dilatation  was  found, 
half  of  them  died  in  the  postfebrile  period. 


132  CLINICAL  OBSERVATIONS 

The  relation  of  cardiac  dilatation  to  symptoms  may  be 
worthy  of  investigation.  In  the  case  of  Autopsy  No.  5  there 
was  slight  dilatation  and  flabbiness  of  the  muscle,  but  the  pulse 
was  relatively  good  until  the  day  of  the  patient's  death.  The 
symptoms  were  those  of  cerebral  toxaemia  and  exhaustion.  In 
the  case  of  Autopsy  No.  12  the  presenting  symptom  was  coma 
associated  with  a  soft  and  irregular  pulse;  and  in  the  case  re- 
ferred to  under  Autopsy  No.  22  weakness  of  the  pulse  was  the 
only  striking  symptom  for  several  days  before  death.  There 
were  no  important  complications  in  any  of  these  cases.  In  the 
.first  of  them  the  pulse  gave  no  warning,  by  feebleness  or  irregu- 
larity, of  weakness  of  the  heart  muscle.  In  the  other  two  cases 
there  was  weakness  and  irregularity  of  the  pulse. 

The  cases  of  Autopsy  Nos.  6,  9,  and  13  showed  dilatation  of 
the  right  ventricle.  In  that  of  No.  6  an  old  mitral  stenosis  was 
found.  The  violent  delirium  of  No.  9  gave  every  reason  to  ex- 
pect cardiac  dilatation  to  develop  even  though  the  pulse  was 
full  and  strong  at  first.  In  the  case  of  No.  13  cardiac  dilatation 
might  have  been  inferred  from  the  fact  that  the  patient  died  in 
an  attack  of  dyspnoea  and  distress. 

The  number  of  cases  is  too  small  to  admit  of  safe  deductions 
as  to  the  relation  of  dilatation  to  symptoms.  The  same  may  be 
said  of  it  as  a  possible  factor  in  causing  death. 

The  only  other  case  in  which  either  clinical  or  pathological 
evidence  points  to  cardiac  death  is  that  of  Autopsy  No.  20. 
In  this  case  there  was  weakness  of  the  pulse  and  myocardial 
changes  were  found  which  seemed  to  be  chronic,  but  the  heart 
was  not  dilated.   This  patient  died  very  suddenly. 

If  it  be  assumed  that  dilatation  of  the  whole  heart,  or  of  the 
right  ventricle,  only  found  at  autopsy,  is  evidence  that  cardiac 
weakness  was  an  important  cause  of  death  in  these  cases  and 
add  to  them  the  one  last  mentioned,  it  may  be  inferred  that 
cardiac  weakness  was  largely  responsible  for  death  in  seven  of 
the  twenty  cases  autopsied. 

But,  if  we  subtract  from  these  cases  the  one  in  which  an  old 
mitral  stenosis  of  extreme  degree  was  found,  and  the  last  case 
in  which  the  myocardial  changes  seemed  to  be  chronic,  there 


TYPHUS  IN  SERBIA  133 

remain  five  cases  in  which  acute  myocardial  weakness  seems  to 
have  led  to  cardiac  dilatation  and  death. 

Three  of  these  five,  however,  died  in  the  postfebrile  period  in 
a  state  of  emaciation  and  exhaustion  from  which  they  were 
unable  to  rally.  Would  it  not  be  reasonable  in  these  cases 
to  suppose  that  death  was  due  chiefly  to  general  exhaustion 
rather  than  to  the  nature  or  degree  of  the  changes  in  the  heart 
muscle? 

This  view  receives  some  support  from  the  histological  find- 
ings of  Dr.  Mallory.  His  studies  of  the  pathological  material, 
however,  are  not  completed  at  the  present  writing,  but  sections 
have  been  examined  from  nine  hearts  selected  to  include  some 
that  were  soft  and  dilated  and  others  that  were  firmly  con- 
tracted. Dr.  Mallory  says  that  sHght  fatty  degeneration  and 
small  foci  of  cellular  infiltration  exist  in  all  of  these  hearts  to 
about  the  same  degree,  but  that  these  changes  are  much  less 
extensive  than  are  usual  in  cases  of  diphtheria. 

The  evidence  at  hand  seems  to  show  that  acute  myocardial  dam- 
age is, seldom  the  most  important  factor  in  death  from  typhus. 

Nevertheless,  circulatory  phenomena  such  as  cyanosis, 
lividity,  coldness  of  the  extremities,  and  a  pulse  which  is  small, 
soft,  and  unequal  or  irregular  are  so  common  in  typhus  cases 
and  develop  so  often  a  number  of  days  before  death,  and  low 
blood-pressure,  small  pulse  pressure,  and  modification  in  the 
heart  sounds  are  so  constant  in  the  severe  cases  of  typhus  that  it 
seems  impossible  to  escape  the  conviction  that  circulatory  abnormal- 
'  ities  are  of  great  importance  and  that  they  are  a  frequent  imme- 
diate or  contributory  cause  of  death. 

The  two  italicized  conclusions  are  reconcilable  if  the  circula- 
tory abnormalities  be  attributed  less  to  myocardial  lesions 
than  to  loss  of  vascular  tone  associated  with  dilatation  of  the 
vessels.  Lesions  in  the  walls  of  the  blood-vessels,  or  the  direct 
effect  of  toxins  upon  them,  or  the  indirect  influence  of  exhaus- 
tion, or  perhaps  a  combination  of  influences  acting  on  the 
vasomotor  mechanism  might  bring  about  the  dilatation. 

Following  this  hypothesis  deaths  occurring  before  the  period  of 
defervescence  may  be  attributed  to  toxaemia  with  resulting  disturb- 


134  CLINICAL  OBSERVATIONS 

ances  of  the  vascular  circulation;  and  later  deaths  could  he  ex- 
plained as  due  primarily  to  general  exhaustion  and  secondarily  to 
vascular  lesions  or  functional  circulatory  derangements. 

My  clinical  observations  accord  well  with  this  hypothesis, 
and,  therefore,  exhaustion  was  assigned  as  the  principal  cause 
of  death  in  six  of  the  seven  cases  in  which  death  occurred  in  the 
postfebrile  period.  In  the  seventh  case  death  was  due  to  severe 
secondary  infection. 

In  the  cases  that  died  earlier  the  toxaemia  affected  different 
systems  in  varying  degrees.  The  case  of  Series  No.  87,  in  which 
there-  was  no  autopsy,  showed  cerebral,  pulmonary,  and  circu- 
latory disturbances  in  a  high  degree.  This  case  seems  to  be  an 
instance  of  severe  general  toxaemia  with  incidental  circulatory 
derangement.  For  two  days  before  death  weakness  and  rapid- 
ity of  the  pulse  was  the  most  alarming  sign.  In  the  case  of 
Autopsy  No.  24,  on  the  other  hand,  exhaustion  was  followed 
late  in  the  disease  by  circulatory  weakness,  and  in  that  of 
Autopsy  No.  9  cerebral  toxaemia  causing  violent  delirium  was 
followed  early  by  physical  exhaustion,  the  pulse  having  been 
good  during  the  period  of  delirious  activity. 

The  first  part  of  the  aorta,  in  a  large  proportion  of  cases, 
showed  a  few  small,  soft,  yellowish  spots.  Whether  or  not  they 
developed  in  the  course  of  the  typhus  or  were  there  before  it 
began  is  doubtful. 

Murchison  ^  says:  —  ^'In  a  large  number  of  cases,  the  mus- 
cular tissue  of  the  heart  is  flabby,  soft,  and  easily  torn.".  .  . 
"The  softening  is  independent  of  the  duration  of  the  disease, 
the  age  of  the  patient,  the  external  temperature,  or  the  interval 
since  death.  In  many  cases  it  is  confined  to  the  left  side  of  the 
heart." 

Curschmann,^  on  the  other  hand,  says:  —  "There  is  almost 
always  unilateral  dilatation  of  the  heart.  In  cases  where  death 
occurs  relatively  early,  the  muscle  is  flabby ,  friable,  dull,  and  of  a 
yellowish  red  color,  with  occasional  reddish  streaks  and  linear 
and  punctate  markings.  We  unquestionably  have  to  deal  with 
the  form  of  infectious  myocarditis  that  has  recently  been 

1  Murchison:  loc.  cit.  ^  Curschmann:  loc.  cit. 


TYPHUS  IN  SERBIA  135 

studied  by  the  aid  of  modern  microscopic  technic  in  typhoid 
fever,  scarlet  fever,  diphtheria,  etc." 

The  histological  changes,  according  to  Moore,^  are  cloudy 
swelling  and  granular,  fatty  degeneration  in  the.  heart  muscle. 
Hyaline  degeneration  and  necrosis  of  the  inner  coats  of  the  small 
vessels  in  the  skin  were  observed  by  Prowazek. 

The  fact  that  in  ten  out  of  twenty  of  our  autopsy  cases  the 
heart  was  found  contracted  and  that  the  muscle  of  the  left 
ventricle  was  soft  in  only  two  of  these  cases  is  of  interest  in  rela- 
tion to  Murchison's  ^  experience.  In  one  of  our  cases  the  right 
ventricle  was  dilated  and  in  two  it  was  relaxed.  Autopsy  No. 
9,  the  only  case  in  which  death  occurred  relatively  early, 
showed  softness  of  the  muscle  and  dilatation  of  the  right 
ventricle  such  as  Curschmann's  ^  statement  would  lead  one  to 
expect. 

The  theory  which  regards  circulatory  disturbances  of  vas- 
cular origin  as  an  important  cause  of  death  receives  some  sup- 
port from  the  findings  of  Prowazek.* 

SUMMAEY 

Lesions  have  been  found  in  both  heart  and  vessels  in  tj^hus. 
Clinical  signs  point  to  weakness  of  the  heart  in  some  cases,  and 
to  vascular  dilatation  in  others.  Most  often  the  symptoms 
point  to  a  combination  of  cardiac  weakness  and  vascular  dilata- 
tion. 

The  observations  of  Stokes  ^  and  of  Jenner  ^  in  typhus  and 
other  fevers,  the  clinical  work  of  Curschmann  "^  and  of  Ortner  ^ 
in  typhoid,  Wiesel's  ^  histological  studies  of  the  heart  and  blood- 
vessels in  typhoid,  and  the  experiments  of  StejskaP°  and  of 
Romberg's^^  pupils  with  toxic  substances,  and  the  study  of  the 
pathology  of  the  heart  in  diphtheria  by  Councilman,  Mallory, 

1  Moore :  loc.  cit.  ^  Stokes:  loc.  cit. 

^  Murchison:  loc.  cit.  ^  Jenner:  loc.  cit. 

^  Curschmann:  loc.  cit.  ^  Curschmann :  loc.  cit. 

*  Prowazek:  loc.  cit.  ®  Ortner:  loc.  cit. 

9  Wiesel:  Prag.  Ztschr.  f.  Heilk.,  1905,  xxvi,  107. 
i»  Stejskal:  Ztschr.  f.  klin.  Med.,  1902,  xliv,  367;  1903,  li,  129. 
"  Romberg:  Deut.  Arch.  f.  klin.  Med.,  1899,  Ixiv,  652. 


136  CLINICAL  OBSERVATIONS 

and  Pearce  ^  are  of  special  interest  in  connection  with  the 
problem. 

Tests  of  the  functional  capacity  of  the  vasomotor  mechanism 
and  of  the  heart  muscle  have  recently  been  performed  by  Por- 
ter and  Newburgh  ^  in  experimental  pneumonia,  and  Means  ^ 
has  studied  the  respiratory  mechanism  in  pneumonia.  The 
work  of  these  men  is  extremely  significant,  throwing  further 
light,  as  it  does,  on  the  nature  of  these  circulatory  changes. 

V.   Blood 

Counts  of  the  red  and' white  cells,  differential  counts,  ex- 
amination of  blood  smears,  and  Widal  tests  were  performed 
by  Dr.  Sellards,  and  have  been  discussed  by  him  in  another 
paper. 

Dr.  Sellards  also  made  haemoglobin  determinations  of  blood 
from  the  ear  with  Sahli's  instrument.  In  some  instances  the 
percentages  found  were  far  above  normal. 

My  own  estimations  were  made  with  the  Tallquist  scale 
which  is  not  adapted  for  abnormally  high  concentrations.  In 
some  cases  it  was  evident  that  the  blood  was  darker  in  color 
than  the  100  per  cent  shade  of  the  scale,  and,  accordingly, 
the  observation  was  recorded  as  110  per  cent  or  100  per 
cent  plus. 

Determinations  by  both  the  Tallquist  and  Sahli  methods 
have  been  recorded  on  the  charts  of  the  illustrative  cases. 

There  were  marked  differences  in  the  results  of  the  two 
methods.  In  an  extreme  instance  of  this  sort  the  Sahli  reading 
was  135  per  cent  and  the  Tallquist  reading  85  per  cent  on  the 
same  day.  More  often,  high  color  of  the  blood  was  recognized 
by  means  of  the  Tallquist  scale  and  recorded  as  110  per  cent  or 
100  per  cent  plus,  but  the  Sahli  estimations  were  doubtless 

'  Councilman,  Mallory,  and  Pearce:  "Diphth.  pathology  of  incl.  heart."  Jour.  Bos- 
ton Soc.  Med.  Sc,  1900,  v,  139. 

2  Porter  and  Newburgh:  Am.  Jour.  Physiol.,  1908,  xxiii,  131;  Boston  Med.  and  Surg. 
Jour.,  1908,  clviii,  73;  Am.  Jour.  Physiol.,  1914,  xxxv,  1;  Am.  Jour.  Med.  Sc,  1915,  cxlix, 
204;  Jour.  Exper.  Med.,  1915,  xxii,  123;  Am.  Jour.  Physiol.,  1915,  xxxvi,  418. 

3  Means,  Newburgh,  and  Porter:  Boston  Med.  and  Surg.  Jour.,  1915,  clxxiii,  742; 
ibid.,  1916,  clxxiv,  464. 


TYPHUS  IN  SERBIA  137 

more  accurate.  Discrepancies  may  be  explained  in  part  by  the 
fact  that  estimates  by  the  two  methods  were  never  made 
simultaneously  and  local  circulatory  changes  may  have  oc- 
curred in  the  interval. 

High  haemoglobin  percentages  with  more  or  less  increase  of 
the  red  count  were  obtained  in  the  cases  of  Series  Nos.  9  and  10. 
These  were  among  a  group  of  patients  that  had  spent  several 
days  on  the  train  before  reaching  the  hospital.  All  of  them 
were  not  only  markedly  emaciated,  but  they  also  presented  a 
dried  up  appearance  as  if  they  had  not  received  sufficient  fluid. 
Their  high  red  counts  might,  therefore,  be  accounted  for  on  the 
basis  of  dehydration  of  the  blood  as  a  whole.  The  estimate  of 
haemoglobin  of  135  per  cent  above  mentioned  may  have  been 
due  to  similar  causes. 

Another  possible  explanation  for  high  red  counts  combined 
with  high  haemoglobin  is  irregular  distribution  with  local  ac- 
cumulation of  red  cells.  The  frequent  occurrence  of  marked 
local  hyperaemia,  often  associated  with  slight  cyanosis  of  the 
ears,  favors  this  hypothesis  as  the  more  probable  in  some  cases, 
if  not  in  all. 

Authority  for  such  an  hypothesis  is  provided  by  Cabot, ^ 
Wood,^  and  Sahli.^ 

Increase  of  the  color  indices  is  not  so  easily  explainable.  The 
indices  were  1.13  in  No.  9,  and  1.10  in  No.  10,  the  cases  cited 
above.  In  Series  No.  47  with  a  normal  red  count  the  index  was 
approximately  1.15.  In  Series  Nos.  1  and  57,  although  the  red 
counts  were  slightly  low,  the  indices  were  stiU  higher.  They  were 
respectively  1.75,  and  approximately  1.30. 

In  the  days  when  bleeding  was  practised  as  a  routine  in  fever 
it  was  observed  that  the  blood  of  typhus  patients  was  ab- 
normally dark  in  color  and  slow  to  clot.  Dark  color  and 
fluidity  of  the  blood  at  autopsy  has  been  commented  upon 
repeatedly,  and  was  observed  also  by  us.  The  question  suggests 
itself  as  to  whether  methaemoglobin  is  formed  in  typhus.   The 

1  Cabot:  CUn.  Exam,  of  the  Blood,  N.  Y.,  1901,  p.  75. 

2  Wood-  Chem.  and  Mic.  Diag.,  N.  Y.,  1909,  p.  127. 

3  Sahli:  Diag.  Methods,  Trans.,  Phil.,  1905,  p.  628. 


138  CLINICAL  OBSERVATIONS 

studies  of  Peabody  ^  with  the  pneumococcus  suggests  that  this 
may  be  the  case.  If  so,  a  high  color  index  could  be  attributed 
to  the  presence  of  methaemoglobin. 

Repeated  haemoglobin  estimations  by  the  Tallquist  scale  in- 
dicated that  a  slight  anaemia  develops  in  the  later  stages  of 
typhus.  Pallor  during  convalescence  lent  support  to  this  view, 
and  Curschmann  ^  states  that  diminution  of  red  count  and  of 
haemoglobin  is  found  at  the  height  of  the  fever  and  during 
convalescence. 

VI.   Respiratory  Signs  and  Symptoms 

Epistaxis  was  observed  several  times  at  the  height  of  the 
disease  (Series  No.  21).  Slight  bleeding  during  convalescence 
was  evidently  caused,  in  one  instance,  by  picking  the  nose 
which  was  ulcerated  from  herpes.  Murchison  ^  says  that 
epistaxis  is  rare  in  typhus.  Certainly,  it  is  iiot  so  commonly  an 
early  symptom  as  in  typhoid. 

Pharynx  and  Tonsils.  Reddening  of  the  pharynx,  the  pillars 
of  the  fauces,  and  the  tonsils,  with  slight  swelling  of  the  latter, 
seems  to  be  common  in  the  earlier  stages  of  typhus.  Pro- 
nounced catarrh  of  the  pharynx  associated  with  accumulation 
of  tenacious  sticky  mucus  which  clogs  the  patient's  throat  and 
which  is  difficult  for  him  to  expel  is  a  later  condition.  Toward 
the  end  of  the  period  of  high  fever  dried  mucus  is  often  seen 
adhering  to  the  pharynx  and  giving  it  a  glazed  appearance. 

The  Larynx  was  seriously  affected  in  only  one  of  my  pa- 
tients. He  was  very  ill  when  I  first  saw  him  and  could  scarcely 
make  a  sound.  Later,  he  developed  peculiar  sepulchral  tones. 
The  voice  was  husky  throughout  convalescence  but  the  sub- 
sequent recovery  was  complete. 

In  several  other  cases  slight  hoarseness  was  observed.  None 
had  obstructing  oedema.  Oedema  of  the  larynx  is  one  of  the 
recognized  dangers  in  typhus  fever. 

Lungs.   Signs  varied  from  those  of  slight  passive  congestion 

1  Peabody:  Jour.  Exp.  Med.,  1913,  xvii,  587;  1913,  xviii,  1  and  7. 

^  Curschmann:  loc.  cit. 

^  Murchison:  loc.  cit.  ^ 


TYPHUS  IN  SERBIA  139 

of  the  bases  to  evidence  of  rapidly  developing,  generalized 
oedema.  Bronchitis  was  slight  or  severe.  Lobular  and  lobar 
pneumonia  were  observed.  Pain  in  the  chest,  probably  pleu- 
ritic, was  not  uncommon,  but  no  perfectly  characteristic  fric- 
tion rub  was  heard,  and  pleural  effusion  was  neither  diagnosed 
nor  found  at  autopsy. 

Bronchitis.  Autopsy  generally  showed  the  bronchial  mucosa 
slightly  swollen,  injected,  and  bathed  in  glairy,  sticky,  blood- 
stained mucus.  In  other  cases  the  bronchial  secretion  was 
mucopurulent. 

Bronchitic  rales  were  found  in  almost  every  case  sooner  or 
later.  They  increased  as  the  fever  advanced.  They  were  scat- 
tered bilaterally  throughout  the  chest.  The  rales,  as  a  rule, 
were  of  the  coarse,  moist  type;  but  piping  rales  were  heard  fre- 
quently. When  the  bronchitis  was  pronounced,  sonorous 
rhonchi  and  'fine  moist  rales  were  often  present.  The  rhonchi 
could  be  heard  all  over  the  chest,  but  especially  in  the  upper 
part;  and  the  fine  rales  were  generally  limited  to  the  bases, 
indicating  that  passive  congestion  was  superimposed  upon  the 
bronchitis. 

Passive  Congestion  was  not  found  clinically  except  in  the 
severer  cases,  and  in  these  it  was  obscured  by  the  bronchitis. 
Good  nursing,  I  think,  kept  it  at  a  minimum.  In  fatal  cases 
which  came  to  autopsy,  however,  passive  congestion  was  found 
nearly  always,  and  sometimes  it  was  extreme. 

Pneumonia,  as  a  complication,  was  diagnosed  at  first  on  the 
basis  of  rapid,  shallow,  and  labored  breathing  associated  with 
inspiratory  extension  of  the  nostrils,  use  of  the  accessory 
muscles  of  respiration,  and  rather  indefinite  signs  of  consolida- 
tion consisting  of  slight  dulness  and  distant  bronchial  breath- 
ing. The  autopsy  findings  in  some  of  these  cases,  however, 
were  not  typical  of  pneumonia,  so  that  this  diagnosis  was  later 
made  with  more  reserve.  This  subject  is  again  discussed  under 
"Complications." 

Atelectasis  of  small  portions  of  the  lung  was  found  in  several 
autopsies  and  may  have  explained  some  of  the  signs  attributed 
to  pneumonia. 


140  CLINICAL  OBSERVATIONS 

Respiration.  Movement  of  the  nostrils  and  rapid  but  easy 
breathing  was  sometimes  observed  when  there  was  no  passive 
congestion  and  Httle  if  any  bronchitis.  In  such  cases  the  rapid 
breathing  has  been  attributed  by  most  authors  to  the  action  of 
toxins.  Dissociation  between  the  rates  of  pulse  and  respiration 
in  typhus  has  been  observed  by  many.  Methaemoglobinaemia, 
if  present,  may  have  been  a  factor,  and  the  question  of  acidosis 
requires  consideration. 

In  other  cases  in  which  the  breathing  was  rapid  and  labored, 
extensive  bronchitis,  or  congestion,  or  both  seemed  to  be  the 
essential  factors  in  its  production.  Series  Nos.  21  and  87  died, 
apparently,  by  gradual  drowning :  which  seems  also  to  happen 
in  some  cases  of  pneumonia.  There  was  no  autopsy  in  either 
of  these  cases  so  that  pneumonia  cannot  be  excluded.  Exten- 
sive pulmonary  oedema  existed  undoubtedly  in  both  cases. 
These  patients  were  obliged  to  struggle  for  breath  for  several 
days  before  death,  without  rest  or  sleep. 

The  Sputum  in  cases  of  this  sort  was  extremely  viscid  and 
could  be  expelled  by  the  patient  only  with  the  greatest  diffi- 
culty. It  was  often  blood  streaked.  In  other  cases  with  mani- 
fest bronchitis  it  was  mucopurulent  or  purulent. 

Pulmonary  symptoms  were  far  more  prominent  in  my  typhus 
patients  than  they  commonly  are  in  typhoid  or  in  any  other  dis- 
ease with  which  I  am  familiar,  except  pneumonia.  Pneumonia 
as  a  complication  is  discussed  below. 

Cough  was  a  constant  symptom.  In  many  cases  it  was  dis- 
tressing not  only  by  its  frequency  but  also  because  of  the  effort 
required  to  expel  the  sticky  secretion.  Sometimes  the  patient 
almost  choked  in  the  process. 

The  Sputum,  as  a  rule,  was  mucoid,  tenacious,  sometimes 
frothy,  and  often  tinged  or  streaked  with  blood.  At  first  it  was 
glairy,  later  whitish,  yellowish,  or  mucopurulent.  Occasionally 
it  was  purulent,  but  this  was  due,  probably,  to  a  well-marked 
complicating  bronchitis.  Microscopical  examinations  were 
made  in  three  cases  in  which  pulmonary  complications  existed. 

For  several  days  one  of  these  patients  lay  propped  up  in  bed, 
the  accessory  muscles  brought  actively  into  play,  and  the 


TYPHUS  IN  SERBIA  141 

breathing  rapid  and  laborious.  The  sputum  was  abundant, 
mucopurulent,  and  contained  influenza-like  bacilli  and  Micro- 
coccus catarrhalis  in  large  numbers,  as  well  as  a  few  pneumococci 
and  some  large  bacilli.  Bronchopneumonia  almost  certainly 
existed  in  this  case. 

The  sputum  in  the  case  of  Series  No.  93  consisted  of  very 
viscid,  thick,  whitish  mucus,  and  contained  few  leucocytes. 
There  were  many  pneumococci  and  various  other  bacteria, 
among  them  a  few  influenza-like  bacilli  and  spirochaetae.  At 
times  the  sputum  was  foul-smelling  and  purulent  but  never 
copious,  and  a  secondary  rise  of  temperature  occurred  when  the 
pulmonary  symptoms  became  most  marked.  Gangrene  and 
bronchiectasis  were  considered,  but  inasmuch  as  the  cough  and 
expectoration  cleared  up  later  it  was  probably  a  case  of  bron- 
chitis and  bronchopneumonia  with  retained  secretion. 

A  third  patient  (Series  No.  59)  undoubtedly  had  pulmonary 
gangrene.  A  large  quantity  of  frothy,  tenacious  sputum  which 
later  became  extremely  offensive  was  brought  up  in  fits  of 
laborious,  spasmodic  coughing  during  convalescence.  Signs  of 
trouble  were  found  at  the  right  base  and  there  was  pain  in  this 
region.  The  sputum  contained  great  numbers  of  influenza-like 
bacilli,  a  few  pneumococci,  and  bacteria  of  other  kinds.  Re- 
covery was  slow. 

Tubercle  bacilli  were  looked  for  in  these  cases  but  none  were 
found. 

VII.   Pathology  of  the  Respiratory  System 

The  more  severe  lesions  found  at  autopsy  are  described  be- 
low under  "Complications  and  Sequelae." 

Bronchitis  with  swelling  and  redness  of  the  mucous  mem- 
brane has  been  described  by  others  and  is  probably  present  in 
most  severe  cases  of  typhus. 

Passive  congestion  was  found  in  most  of  our  fatal  cases,  but 
not  invariably.   There  was  none  in  the  case  of  Autopsy  No.  21. 

Series  No.  21,  in  which  there  was  no  autopsy,  certainly  died 
from  asphyxia  preceded  by  gradually  increasing  bronchitis, 
and  pulmonary  oedema.  Perhaps  there  was  pneumonia  as  well. 
Just  before  death  the  pulse  was  remarkably  fuU  and  strong. 


142  CLINICAL  OBSERVATIONS 

This  was  due  probably  to  the  rise  of  blood-pressure  which 
usually  accompanies  asphyxia. 

Wiener  found  lobar,  lobular,  or  "  hjrpostatic  "  pneumonia  in 
one-third  of  his  39  autopsies.  He  mentioris  finding  petechial 
haemorrhages  in  the  larynx  and  large  bronchi.  To  these  he 
attributed  the  bloody  sputum  of  some  cases. 

Bronchitis  and  pulmonary  congestion  in  typhus  seem  seldom 
to  result  in  death  unless  there  is  marked  circulatory  disorder, 
severe  general  toxaemia,  extreme  exhaustion,  or  pneumonia  as 
well.   Series  No.  21  was  unique  among  our  cases  in  this  respect. 

There  seem  to  be  several  varieties  of  pulmonary  congestion. 
Sometimes  it  is  chiefly  of  the  hypostatic  or  passive  type.  In 
other  cases  it  is  localized  in  circumscribed  areas  and  is  intensely 
haemorrhagic  in  character  suggesting  that  lobar  pneumonia 
was  developing.  In  still  other  cases  in  which  congestion  was  not 
localized,  the  secretion  was  so  viscid  as  to  point  to  inflammation 
rather  than  passive  congestion  as  its  cause.  In  these  cases  it 
seemed  to  result  from  an  intense  bronchitis.  These  three  types 
of  process  were  often  so  intermingled  as  to  render  interpreta- 
tion of  the  findings  difficult  (see  "Pulmonary  Comphcations"). 

The  findings  of  Means,  Newburgh,  and  Porter  ^  in  experi- 
mental pneumonia  may  have  counterparts  in  typhus.  If  so, 
disturbances  of  the  respiratory  mechanism  may  play  an  im- 
portant part  in  producing  serious  symptoms  or  death  in  typhus, 
and  perhaps,  some  of  the  circulatory  disturbances  are  second- 
ary to  disorders  of  respiration. 

Peabody's  ^  discovery  of  methaemoglobin  in  the  blood  of 
severe  cases  of  pneumonia  suggests  that  it  may  be  formed  also 
in  typhus,  and  that  it  may  explain  the  existence  of  cyanosis  or 
dusky  discoloration  of  the  face  in  some  cases  in  which  the  con- 
dition of  the  lungs  and  general  circulation  do  not  seem  to 
warrant  the  change  in  color. 

YIII.   Digestive  System:  Signs  and  Symptoms 

The  Tongue  was  always  coated,  white  at  first,  becoming  later 
brown,  dry,  and  often  cracked.   This  is  the  ''parrot  tongue"  of 

1  Means,  Newburgh,  and  Porter:  loc.  cit.  ^  Peabody:  loc.  cit. 


TYPHUS  IN  SERBIA  143 

typhus.    During  convalescence  it  turned  red  along  the  edges 
first. 

Brown  Sordes  accumulated  with  great  rapidity  on  the  teeth, 
so  much  so  that  in  very  sick  patients  it  was  practically  impos- 
sible for  the  nurses  to  keep  the  mouth  clean  for  an  hour. 

Anorexia  was  marked,  as  a  rule,  while  the  fever  remained 
high,  but  appetite  often  began  to  return  early  in  defervescence, 
and  was  generally  good  before  the  end  of  the  febrile  period. 
Many  patients  at  this  stage  would  sit  up  in  bed  and  beg  for 
more  black  bread  when  they  were  already  receiving  the  usual 
amount  and  much  other  nourishment. 

Vomiting  of  greenish  bile  occurred  in  a  few  cases.  It  was 
persistent  only  in  one  case  (Series  No.  57).  No  special  cause 
was  found  for  the  symptom. 

Haematemesis  was  observed  once.  It  did  not  recur,  nor  was  it 
followed  by  other  gastric  symptoms. 

Abdomen.  Pain  was  seldom  complained  of,  but  slight  gen- 
eralized sensitiveness  to  firm  pressure  was  common.  Gerhard  ^ 
says  that  abdominal  sensitiveness  in  typhus  is  usually  a  mani- 
festation of  a  general  hyperalgesia  of  the  muscles  or  skin.  This 
was  true  in  some  of  my  cases,  but,  as  a  rule,  I  think  the  sensi- 
tiveness was  local. 

The  abdomen,  generally,  was  flat  or  concave  and  quite  unlike 
the  doughy,  slightly  distended  abdomen  of  typhoid. 

Meteorism  was  unusual.  It  occurred  in  a  few  of  the  sicker 
patients  who  recovered  and  in  a  number  of  fatal  cases  (Series 
No.  87,  death  but  no  autopsy). 

Pain  and  swelling  in  the  lower  abdomen  resulting  from  over- 
distention  of  the  bladder  was  seen  in  several  cases  (Series  No.  9 
and  Autopsy  No.  24). 

Gurgling  in  the  right  iliac  fossa  was  noted  in  two  cases. 
Murchison  ^  says  that  it  is  quite  exceptional  in  typhus,  and 
that  when  it  does  occur  it  is  not  limited  to  the  right  iliac  fossa, 
and  that  it  is  associated  with  diarrhoea.  One  of  my  cases  does 
not  bear  out  this  statement,  for  this  patient  had  no  diarrhoea. 
However,  the  gurgling  may  have  been  due  to  the  transitory 

1  Gerhard:  loc.  cit.  ^  Murchison:  loc.  cit. 


144  CLINICAL  OBSERVATIONS 

effect  of  a  cathartic.  In  Series  No.  57  the  gurgling  was  most 
marked  in  the  right  iHac  fossa,  but  was  not  hmited  to  that  re- 
gion.  Here,  again,  there  was  no  diarrhoea. 

The  Stools  that  I  saw  were  dark  colored,  fluid,  and  rather  uni- 
form in  appearance.  A  nurse  told  me  that  they  were  always 
liquid,  but  this  may  have  been  due  to  free  use  of  cathartics,  for 
Murchison  ^  says  that  when  the  bowels  move  spontaneously 
without  medicine  the  stools  are  usually  of  normal  consistency 
and  color. 

Diarrhoea  was  pronounced  in  a  few  cases  and  slight  in  others. 
It  began  most  often  with  the  first  indications  of  defervescence 
and  lasted,  as  a  rule,  only  two  or  three  days.  Series  No.  59  had 
exceptional  looseness  of  the  bowels.  The  day  before  the  crisis 
when  his  condition  was  desperate,  they  moved  seven  times. 
The  diarrhoea  continued  for  a  considerable  number  of  days  and 
required  opium  to  control  it.  A  patient  of  Dr.  Smith's  that  I 
did  not  think  could  live  another  day  developed  a  severe 
diarrhoea  coincident  with  the  beginning  of  convalescence. 
Several  fatal  cases  also  had  diarrhoea  (Autopsy  No.  24),  and 
it  was  troublesome  in  Series  No.  93. 

The  Spleen  was  felt  in  a  small  proportion  of  cases  only.  In  a 
larger  proportion  there  was  increase  of  dulness  in  the  splenic 
region.  Adding  together  these  two  groups  of  cases  and  assum- 
ing that  the  increase  of  dulness  was  due  to  splenic  enlargement, 
there  was  evidence  of  enlargement  at  the  first  examination  in 
about  haK  the  cases.  When  not  palpable  at  first  the  spleen  was 
not  felt  later.  Curschmann  ^  says  that  the  "  enlargement  rarely 
exceeds  a  moderate  degree,  and  the  consistence  of  the  organ  is, 
on  the  average,  less  than  in  other  infectious  diseases."  He  be- 
lieves that  the  spleen  can  be  felt,  however,  in  most  cases  if 
examined  early  enough;  that  the  enlargement  comes  with  the 
first  symptoms  and  that  it  generally  disappears  before  the 
beginning  of  defervescence.  Failure  to  feel  the  spleen  may  be 
accounted  for  in  some  cases  probably  by  extreme  softness  of  the 
organ,  and  in  other  cases  because  it  may  no  longer  be  enlarged 
when  the  patient  is  first  seen  at  a  late  stage  of  the  disease. 

^  Murchison:  loc.  cit.  ^  Curschmann :  loc.  cit. 


TYPHUS  IN  SERBIA  145 

The  Liver  edge  was  felt  in  a  few  cases.  There  was  never  much 
enlargement. 

In  1861  Barrallier  ^  (quoted  by  Murchison^)  found  slight  en- 
largement of  the  liver  in  30.6  per  cent  of  365  cases. 

Jaundice  is  not  mentioned  by  Murchison  ^  but  Michie  ^ 
found  ^^ slight  haematogenous  jaundice"  in  cases  of  Mexican 
typhus,  and  Michaud*  saw  five  cases  of  jaundice  associated 
with  enlargement  of  the  liver  among  fifty-eight  cases  of 
European  typhus.  He  found  urobilinuria  in  twenty-one  cases 
of  the  same  series.  Wiener  ^  says  that  he  saw  jaundice  fre- 
quently in  Hungary.  Repeated  tests  for  bile  in  high-colored 
urines  from  our  cases  were  negative,  nor  was  jaundice  observed 
in  any  of  them. 

Intestinal  Parasites.  An  ascaris  was  vomited  up  by  several 
patients. 

IX.   Pathology  of  the  Digestive  System 

Intestines.  With  the  exception  of  a  few  minute  ecchymoses 
found  occasionally  on  the  serous  surfaces,  and  marked  disten- 
tion of  the  stomach,  colon,  or  intestines  in  a  few  instances, 
nothing  abnormal  was  observed. 

Autopsy  No.  26,  however,  in  which  endocarditis  was  found 
and  the  diagnosis  of  typhus  uncertain,  showed  many  minute 
red  dots  on  the  mucosa  at  the  lower  end  of  the  ileum. 

Wiener  ^  says  that  haemorrhages  in  the  submucosa  of  the 
colon  can  often  be  seen  from  without,  that  they  are  dark  red, 
generally  sharply  circumscribed  and  paler  at  the  edges.  They 
varied  much  in  size,  and  the  extravasation  sometimes  extended 
all  over  the  colon.  Ecchymoses  in  or  on  the  intestines  have 
been  described  also  by  others. 

Gastou  ^  found  the  mucosa  of  the  intestines  and  especially 
that  of  the  colon  congested,  the  folds  prominent,  and  the  walls 
thickened. 

The  Liver  often  showed  nutmeg  markings.   Sometimes  it  was 

1  Barrallier:  Du  typhus  epid^mique  a  Toulon,  Paris,  1861. 

2  Murchison:  loc.  cit.  ^  Wiener:  loc.  cit. 

3  Michie :  loc.  cit.  ^  Gastou:  loc.  cit. 
■*  Michaud:  loc.  cit. 


146  CLINICAL  OBSERVATIONS 

dark  colored  and  engorged  with  blood.  In  other  cases  it 
seemed  to  show  more  or  less  fatty  degeneration.  Its  size  was 
normal  or  slightly  increased. 

The  Spleen  was  generally  enlarged,  sometimes  much  enlarged 
and  very  soft.   In  a  few  cases  it  was  firm  and  of  normal  size. 

X.    The  Nervous  System:  Signs  and  Symptoms 

Mental  States.  The  facial  expression  varied  between  individ- 
uals and  at  different  stages  of  the  disease.  It  most  often  ex- 
pressed stolid  patience,  indifference,  or  lethargy  until  toward 
the  end  of  defervescence,  when  the  patients  began  to  ask  for 
more  food  or  to  be  allowed  to  go  home.  Those  that  were  not 
very  toxic  were  less  somnolent  than  is  the  rule  in  typhoid.  As 
the  disease  advanced  the  features  became  sharp  and  drawn. 

In  a  group  of  about  forty  patients  who  entered  my  wards  at 
about  the  same  time,  after  having  spent  many  hours,  if  not  days, 
in  transit,  probably  with  little  care,  scanty  food,  and  insuffi- 
cient water,  the  expressions  were  strikingly  alike.  The  face  was 
pinched,  the  malar  flush  pronounced,  the  brows  knitted  im- 
movably as  if  by  pain  long  endured,  and  the  eyes  were  watchful 
but  showed  no  sign  of  emotion.  The  patients  made  no  sound, 
nor  moved  at  all  in  bed.  They  submitted  passively  to  being 
examined,  and  although  fully  conscious,  gave  no  sign  of  interest 
in  what  was  being  done. 

Particularly  in  the  days  immediately  preceding  defervescence 
the  mentality  was  clouded,  and  there  was  usually  quiet  de- 
lirium at  night  if  not  in  the  daytime.  Many  cases  of  this  sort 
had  carphology,  subsultus,  and  intention  tremor  of  the  hands, 
and  in  some  cases  of  severe  toxaemia,  twitching  of  the  jaw  and 
facial  muscles  was  observed.  Twitching  of  the  arm  muscles  was 
brought  on  at  times  by  passive  motion  of  a  limb  or  by  taking 
the  blood-pressure. 

A  Russian  medical  student  (Series  No.  87)  who  showed  all  of 
these  symptoms  retained  enough  understanding  to  grab  for  his 
chart  when  it  was  being  examined  before  him.  Later  he  be- 
came completely  delirious,  and  died  after  a  few  days.  Con- 
trasting with  this  case  was  that  of  a  Serbian  officer  (Series  No. 


TYPHUS  IN  SERBIA  147 

21)  who  apparently  appreciated  his  condition  to  the  end.  His 
nervous  system  showed  Httle  outward  sign  of  intoxication. 

Series  No.  9  was  somnolent  on  admission  and  later  fell  into 
a  stupor  but  was  never  completely  comatose.  This  case  was 
complicated  by  nephritis,  but  the  patient  recovered.  A  fatal 
case  of  Dr.  Holmes'  (Autopsy  No.  12)  was  in  deep  coma  for 
about  two  days  before  death.  The  kidneys  showed  some 
abnormalities. 

Stupor  verging  on  coma  was  the  rule  in  the  sicker  patients 
even  in  the  absence  of  renal  lesions,  and  few  patients  in  which 
it  was  pronounced  got  well. 

The  typhoid  state  with  fatal  issue  was  well  illustrated  in  the 
case  of  Autopsy  No.  24. 

Series  No.  61  was  troublesome  by  trying  to  leave  the  ward. 
He  was  not  violent  or  excited  except  during  one  night  when  he 
had  to  be  tied  in  bed. 

Dr.  Smith  had  a  case  of  wild  delirium  analogous  in  all  re- 
spects to  delirium  tremens.  This  patient  slept  only  when  ex- 
hausted. His  pulse  was  very  full  and  bounding  at  first,  but  he 
died  apparently  from  pulmonary  oedema  or  beginning  pneu- 
monia with  cardiac  dilatation. 

A  patient  of  mine  (Autopsy  No.  25)  was  somnolent  but  easily 
aroused.  For  days  he  refused  food  and  medicine  and  drank 
scarcely  any  liquid.  This  condition  persisted  even  when  the 
temperature  was  down  to  normal. 

Hyperemotionalism  during  the  febrile  period  was  illustrated 
by  a  man  of  middle  age  who  was  extremely  thin  and  feeble 
when  admitted.  He  begged  tearfully  to  be  sent  home,  and  ap- 
parently expected  to  die,  but  he  recovered.  During  conva- 
lescence normal  control  and  cheerfulness  returned  quickly  as  a 
rule. 

Early  in  defervescence  nervous  symptoms  began  to  diminish 
and  the  appetite  to  return  in  favorable  cases.  When  a  change 
for  the  better  was  not  coincident  with  a  fall  of  temperature,  the 
outlook  was  very  unfavorable.  Recovery  of  cheerfulness  and 
mental  activity  was  often  astonishingly  rapid,  but  in  a  few 
cases  intellectual  lethargy  was  persistent. 


148  CLINICAL  OBSERVATIONS 

Marked  intellectual  debility  and  lack  of  control  was  seen  in 
the  case  of  a  nurse  returning  home  some  weeks  after  typhus. 
,  Another  nurse  had  hysterical  tremor,  emotionahsm,  and 
speech  disturbance  which  persisted  for  weeks.  In  this  case  a 
perinephritic  abscess  was  discovered  and  when  it  had  been 
drained  tl^e  symptoms  passed  off.  Her  attack  of  typhus  had 
been  mild.  Hysteria  was  seen  also  in  a  man,  a  big  Serbian,  who 
was  convalescent  and  doing  well  and  who  happened  to  have  old 
suppurating  glands  of  the  neck.  He  developed  tremor,  lame- 
ness, and  became  very  apprehensive  after  seeing  a  patient 
operated  on  for  parotitis.  He  was  relieved  temporarily  by  the 
simplest  suggestive  methods  but  under  like  circumstances  the 
symptoms  recurred  (Series  No.  48). 

Frontal  headache  was  almost  invariably  complained  of  in  the 
earlier  stages  of  the  fever.  It  lasted  several  days  and  did  not 
return.  Sometimes,  also,  there  was  pain  in  the  eyes  or  at  the 
nape  of  the  neck. 

Stiffness  of  the  Neck  and  Kernig's  Sign  were  found  in  a  large 
number  of  cases.  In  a  series  of  thirty-one  cases  the  neck  was 
stiff  in  all  but  three.  The  stiffness  was  slight  in  twenty-one 
cases  and  moderate  or  marked  in  seven  cases. 

Kernig's  Sign  in  the  same  series  was  absent  in  three  cases, 
present  on  one  side  only  in  one  case,  slight  in  twenty-three 
cases,  and  moderately  developed  in  four  cases.  In  one  case 
the  neck  was  moderately  stiff  but  there  was  no  Kernig's 
sign,  in  another  there  was  a  slight  Kernig's  sign  but  the  neck 
was  not  stiff,  and  in  two  cases  neither  sign  was  found.  The 
stiffness  was  due  to  muscular  spasm,  but  could  not  be  ac- 
counted for  by  sensitiveness  of  the  muscles  because  this  was 
much  less  common  than  spasm,  and  was  often  entirely  absent  in 
the  presence  of  spasm.  The  spasm  was  seldom  so  pronounced  as 
is  usual  in  meningitis.  It  was  attributed  to  meningeal  irritation. 
Stiffness  of  neck  or  legs  was  observed  also  in  a  few  cases  of 
disease  which  may  have  been  mild  typhus  but  which  were  not 
so  considered.  It  was  slight  in  these  cases  and  in  none  of  them 
was  it  considerable  enough  to  be  designated  as  "moderate"  by 
comparison  with  that  found  in  the  typhus  cases. 


TYPHUS  IN  SERBIA  149 

One  patient  (Autopsy  No.  23)  had  pronounced  twitching  and 
tonic  spasm  of  the  arms  as  well  as  a  very  stiff  neck.  The  au- 
topsy showed  marked  oedema  of  the  brain  and  small  haemor- 
rhages along  the  vessels  in  the  motor  areas  of  the  cortex. 

Reflexes.  The  knee-jerks  and  abdominal  reflexes  were  notably 
sluggish  in  some  of  the  sicker  patients.  The  abdominal  re- 
flex was  not  always  obtained.  The  knee-jerks  were  present 
except  in  Series  No.  93,  in  which  the  right  knee-jerk  was 
sluggish  and  the  left  was  not  obtained,  in  Autopsy  No.  23,  in 
which  case  there  had  been  pronounced  meningeal  symptoms, 
and  in  two  cases  in  which  other  signs  justified  the  diagnosis  of 
tabes. 

Neuritis  was  not  diagnosed  in  any  case  although  it  may  have 
been  the  cause  of  the  pain  in  the  shoulder  of  Series  No.  93  or  of 
the  weakness  of  the  hands  in  Series  No.  9. 

There  were  no  "tender  toes."  Special  efforts  were  made  to 
avoid  pressure  of  the  bedclothes  on  the  toes  because  this,  prob- 
ably, is  the  cause  of  "tender  toes"  in  typhoid. 

Hyperaesthesia.  One  very  sick  patient  was  so  extremely 
sensitive  that  he  apparently  suffered  great  pain  when  touched 
anywhere.  Several  other  patients  at  the  height  of  the  disease 
showed  a  similar  hypersensitiveness  but  of  lesser  degree.  I  do 
not  remember  having  seen  this  condition  so  strikingly  exem- 
plified in  any  other  disease,  although  it  occurs  sometimes  in 
cases  of  prolonged  sepsis  and  especially  after  the  free  use  of 
morphine.  According  to  Gerhard  ^  and  other  writers  hyper- 
sensitiveness is  common  in  severe  cases  of  typhus. 

This  symptom  was  present  in  slight  degree  in  a  fatal  case  of 
pneumonia  seen  recently. 

XL   Pathology  of  the  Nervous  System 

Marked  cerebral  oedema  was  found  in  two  cases,  the  only 
ones  in  which  the  brain  was  examined  {vide  Autopsy  Nos.  12 
and  23).  Both  cases  have  already  been  mentioned.  The  first 
patient  had  slight  renal  changes  and  died  in  deep  coma.  The 
second  had  tonic  spasms  of  the  arms,  and,  in  addition  to  the 

1  Gerhard:  loc.  cit. 


150  CLINICAL  OBSERVATIONS 

excess  of  fluid  in  the  meninges,  there  were  whitish  streaks  and 
minute  haemorrhages  along  the  vessels  in  the  motor  area. 

Excess  of  fluid  and  more  or  less  oedema  of  the  brain  have 
been  observed  often  not  only  in  typhus  but  also  in  other  in- 
fectious diseases,  but  no  definite  relation  between  oedema  and 
cerebral  symptoms  has  been  proven.  It  is  said  by  older  writers 
to  be  as  common  in  cases  without  pronounced  cerebral  symp- 
toms as  in  those  that  have  them.  The  presence  of  the  fluid  is 
sometimes  accounted  for  by  the  assumption  that  it  replaces 
atrophy.  Until  very  recently  the  fluid  has  not  been  observed 
to  be  under  tension.  Danielopolu  ^  presents  interesting  obser- 
vations on  these  points. 

Cortical  haemorrhages,  also,  have  been  found  in  cases  that 
had  convulsions  but  there  is  doubt  whether  they  were  the 
cause  or  the  result  of  the  convulsions. 

Convulsions  in  typhus  may  be  attributed  to  cerebral  con- 
gestion, to  haemorrhage  or  to  uraemia  (e.  g..  Autopsy  No.  16); 
but  Murchison^  says  that  they  can  sometimes  be  ended  by 
catheterizing  an  overdistended  bladder. 

Inflammatory  foci  were  found  in  the  brain  by  Prowazek.^ 

Embolism,  doubtless,  produces  hemiplegia  in  some  cases, 
and  thrombus  formation  in  the  left  side  of  the  heart  might 
account  for  it. 

Among  our  autopsy  cases  four  at  least  were  comatose  for 
hours  or  days  before  death,  suggesting  cerebral  lesions  or 
toxaemia  as  the  primary  cause  of  death.  In  some  cases  the 
coma  developed  gradually  and  was  not  complete  until  a  few 
hours  before  death.  In  other  cases  it  lasted  for  days.  This  was 
so  in  the  cases  of  Autopsy  Nos.  12  and  21.  The  immediate  or 
secondary  cause  of  death  in  these  two  cases  seems  not  to  have 
been  the  same.  The  former  had  a  weak  and  irregular  pulse  and 
has  already  been  mentioned  in  the  discussion  of  the  pathology 
of  the  circulatory  system  as  a  case  of  cardiac  dilatation.  The 
latter  showed  nothing  abnormal  about  the  heart  except  some 
fibrous  thickening  of  the  mitral  valve  and  there  was  no  pul- 

1  Danielopolu:  Le  Typhus  exanthematique,  Bucarest,  1919. 

2  Murchison:  loc.  cit.  ^  Prowazek:  loc.  cit. 


TYPHUS  IN  SERBIA  151 

monary  oedema  and  little,  if  any,  evidence  of  passive  conges- 
tion in  the  viscera.  Moreover,  the  pulse  was  good  until  shortly 
before  death.  Lesions  of  the  circulatory  system  and  marked 
derangement  of  the  circulation,  therefore,  can  be  excluded  as 
the  primary  cause  of  death  in  this  case.  Pulmonary  lesions  can 
similarly  be  excluded.  Apparently  the  patient  died  from 
cerebral  causes  with  terminal  circulatory  disturbances. 

In  two  other  cases  there  was  marked  and  increasing  pul- 
monary congestion  for  several  days,  probably  due  to  a  com- 
bination of  bronchitis  and  oedema.  Coma  developed  toward 
the  end.  These  patients  probably  died  of  asphyxia  as  did  the 
case  of  Series  No.  21  (see  "Pathology  of  Respiratory  System"). 
The  pulse  in  these  cases  remained  good  until  shortly  before 
death,  but  the  lungs  of  both  showed  extensive  lesions. 

Jurgens  ^  attributes  death  in  defervescence  or  in  the  afebrile 
period  of  typhus  to  cerebral  poisoning  rather  than  to  primary 
cardiac  weakness.  The  writer  recognizes  that  cerebral  symp- 
toms may  persist  in  these  late  stages,  but  thinks  exhaustion 
more  often  important  as  a  cause  of  death  at  this  period  (see 
''  Pathology  of  the  Circulatory  System"). 

Gastou  ^  says  that  the  epidemic  in  Serbia  was  characterized 
by  the  frequency  and  severity  of  derangement  of  the  nervous 
system.  He  found  excess  of  fluid,  sometimes  clear,  sometimes 
cloudy  in  the  meninges  and  ventricles;  thickening  of  the 
arachnoid,  cortical  ecchymoses,  enlargement  of  the  spinal 
ganglia,  and  softening  of  the  cord. 

The  number  of  our  patients  having  stiffness  of  the  neck  and 
Kernig's  sign,  or  both,  is  striking.  None  of  the  authors  quoted 
mention  these  signs  as  being  common  in  typhus.  Certainly, 
however,  they  are  much  less  frequent  in  typhoid  fever  than 
they  were  among  our  typhus  patients. 

Derangement  of  the  nervous  system  with  coma  seemed 
sometimes  to  be  the  primary  cause  of  death,  but  more  often 
severe  general  toxaemia  with  marked  secondary  circulatory 
disturbances  and  extensive  pulmonary  lesions  was  followed  by 
coma  or  deep  stupor  as  its  terminal  phase. 

^  Jurgens:  loc.  cit.  2  Gastou:  loc.  cit. 


152  CLINICAL  OBSERVATIONS 

XII.   Genito-Urinary  System 

Bladder.  The  sicker  patients  were  always  incontinent  for 
a  few  days  before  the  beginning  of  defervescence  or  earUer. 
As  a  rule,  the  bladder  emptied  itself  satisfactorily,  but  one  of 
my  patients  required  the  catheter  twice,  and  another  had  to  be 
catheterized  regularly  for  several  days  (Series  No.  9  and  case  of 
Autopsy  No.  24).  A  third  patient,  in  Dr.  Smith's  wards,  had 
retention  for  several  days.  This  patient  and  the  preceding  one 
died. 

Murchison  ^  says  that  retention  of  urine  may  cause  convul- 
sions and  that  catheterization  may  stop  them. 

Urine.  Albumen  was  often  found  in  small  quantity,  and 
there  were  usually  a  few  casts.  Tests  for  acetone  and  diacetic 
acid  were  made  in  a  few  cases.  They  were  negative.  Acetone 
bodies,  however,  have  been  found  occasionally  in  the  urine 
from  cases  of  typhus.    (Curschmann.^) 

An  enormously  heavy  whitish  precipitate  was  noted  in  the 
urine  which  had  been  standing  in  a  few  cases  during  conva- 
lescence. This  precipitate  was  believed  to  be  composed  of 
urates  (Series  No.  1).  Various  authors  mention  this  as  a  fea- 
ture of  convalescence. 

The  diazo-reaction  was  performed  in  a  considerable  number 
of  cases.  It  was  nearly  always  positive  until  the  beginning  of 
defervescence  when  it  became  atypical  or  negative. 

Haemoglobinuria  was  suspected  in  several  cases  owing  to  the 
smoky  color  of  the  urine  and  the  absence  of  blood  in  the  sedi- 
ment. I  have  failed  to  find  any  author  who  clearly  states  that 
it  occurs  in  typhus.  Moore  ^  speaks  of  "a  dark  color  in  the 
urine  caused  by  typhus  dissolution  of  the  blood,"  and  Aschoff  ^ 
says  that  "haemoglobin  secretion  was  found  in  the  kidneys, 
with  haemosiderin  pigmentation." 

Urobilinuria  was  found  by  Michaud  ^  in  twenty-one  out  of 
fifty-eight  cases  of  typhus.   I  have  seen  no  other  mention  of  it. 

Cases  of  nephritis  are  described  below  under  "Complications 
and  Sequelae." 

^  Cited  by  Gastou:  loc.  cit.  ^  Moore:  loc.  cit.  ^  Michaud:  loc.  cit. 

2  Curschmann:  loc.  cit.  ^  Aschoff :  loc.  cit.  ■ 


TYPHUS  IN  SERBIA  153 

XIII.   Bones  and  Muscles 

Pain  in  the  muscles,  in  the  bones  or  in  the  joints  occurs  at 
various  stages  of  typhus.  With  the  onset  of  fever,  pain  in  the 
back  and  Hmbs  is  common,  and  is  said  to  be  nearly  as  severe  as 
in  smallpox.  Many  of  my  patients  in  the  early  stages  of  the 
eruption  complained  of  pain  in  the  legs.  It  was  often  asso- 
ciated with  sensitiveness  of  the  muscles  of  the  calf,  and  some- 
times of  the  hamstrings  as  well. 

During  convalescence,  again,  nearly  all  patients  complained 
of  pain  in  the  legs  and  feet.  No  objective  cause  for  it  was 
found. 

Muscular  twitching  and  spasm  has  been  discussed  under  the 
head  of  the  nervous  system. 

Atrophy  of  individual  muscles,  most  often  affecting  the 
deltoid,  has  been  frequently  recorded  but  was  not  observed  by 
the  writer. 

In  the  case  of  Series  No.  9  there  was  atrophy  of  the  small 
muscles  of  the  hands. 

XIV.    Organs  of  Special  Sense 

Eyes.  More  or  less  injection  of  the  conjunctivae  was  found  in 
practically  every  case.  It  seemed  to  correspond  to  the  flushing 
of  the  face  and,  probably,  it  often  appeared  before  the  eruption. 
It  persisted  until  the  end  of  the  fever,  but  was  most  marked  at 
first.  Sometimes  it  covered  the  conjunctiva,  but  in  other  cases 
it  was  limited  to  the  part  exposed  between  the  lids  or  to  one 
side  of  the  conjunctiva.  Occasionally  it  was  present  in  only  one 
eye. 

Photophobia,  if  it  existed,  was  slight. 

Many  authors  speak  of  the  "ferret  eyes  "  of  typhus,  and  it  is 
assumed  that  the  comparison  has  reference  to  color  rather  than 
to  any  pecuHarity  of  expression,  although  watchfulness  is 
mentioned  by  several  writers  and  one  of  them  says  that  con- 
traction of  the  pupils  is  the  characteristic  of  '^ferret  eyes." 

The  pupils,  as  a  rule,  were  not  remarkable,  but  in  some  cases 
in  the  stage  of  nervous  excitement  slight  contraction  was  ob- 


154  CLINICAL  OBSERVATIONS 

served,  and  in  a  number  of  patients  whose  condition  was 
critical  pupillary  contraction  was  moderate  or  even  extreme. 

Wide  dilatation  of  the  pupil  followed  a  few  days  later  but 
contraction  was  seen  in  the  case  of  Autopsy  No.  17.  Dilatation 
has  been  observed  as  a  precursor  of  death  by  others,  but  the 
writer  has  no  note  of  its  occurrence  under  these  circumstances 
in  typhus. 

Pupillary  contraction  seems  to  be  a  rough  index  of  toxaemia. 

Corneal  ulceration  developed  in  a  few  cases  in  spite  of  care, 
and  all  of  the  patients  in  whom  it  appeared  eventually  died 
(Autopsy  No.  25). 

Ears.  Bilateral  deafness  without  purulent  otitis  media  is  so 
common  in  typhoid  that  it  was  a  surprise  to  the  writer  not  to 
find  it  so  in  typhus.  When  deafness  was  observed  it  was  gen- 
erally unilateral,  and  nearly  always  followed  by  a  purulent  dis- 
charge from  the  affected  ear.  In  a  few  cases  there  was  pain  for 
a  few  days  but  no  discharge.  Deafness  is  stated  by  several 
authors  to  be  very  common  in  typhus. 

Herpes  on  the  ears  was  mentioned  above  under  the  head  of 
^^Skin." 

XV.    Complications  and  Sequelae 

Urticaria  was  seen  in  five  or  six  cases  during  the  febrile 
period,  and  was  probably  caused  by  unsuitable  diet.  The  food 
available  was  far  from  ideal  for  febrile  patients,  and  could  be 
supplemented  only  in  part  from  the  special  stores  of  the  Lady 
Paget  Hospital. 

Erysipelas,  starting  near  the  nostril  or  from  a  discharging 
ear,  was  observed  in  several  cases.  In  the  cases  that  I  saw  it 
was  accompanied  by  little  constitutional  disturbance  and  soon 
cleared  up. 

Suppurative  Lesions.  During  the  convalescent  stage  ab- 
scesses were  not  uncommon  and  sometimes  they  were  large. 
One  patient  had  empyema  of  the  knee-joint,  followed  by  an 
abscess  near  the  thyroid  gland.  Perinephritic  abscess  was  a 
late  sequel  in  one  case. 

Small  boils  were  common.  They  sometimes  appeared  suc- 
cessively, but  never  in  crops. 


TYPHUS  IN  SERBIA  155 

No  case  of  ulceration  in  the  throat  or  of  noma  was  encoun- 
tered among  our  patients,  although  Dr.  R.  P.  Strong  informed 
me  that  at  Monastir  he  had  seen  cases  of  this  sort. 

There  were  very  few  bedsores  which  is  remarkable  consider- 
ing the  number  of  patients  who  were  incontinent  for  longer  or 
shorter  periods.    Much  credit  is  due  the  nurses  for  this. 

Parotitis  was  a  frequent  complication  of  the  periods  of  defer- 
vescence and  convalescence.  I  saw  many  cases  in  other  wards 
but  had  few  in  my  own.  In  one  of  these  cases  (Series  No.  60) 
unilateral  parotitis  appeared  when  the  rash  was  still  visible  on 
the  body.  It  developed  gradually.  The  swelling  was  very  hard 
and  but  slightly  sensitive,  improved  under  poulticing,  flared  up 
several  times  as  if  about  to  suppurate,  and  finally  began  slowly 
to  disappear.  Some  swelling  still  remained  when  the  patient 
was  discharged  from  the  hospital.  No  incision  was  required  in 
this  case. 

In  a  second  case,  when  the  temperature  was  dropping  rapidly 
toward  normal,  parotitis  first  appeared  on  the  right,  and  on  the 
following  day  on  the  left.  (Plate  XXVI,  Figure  1.)  Incision 
on  both  sides  and  under  the  chin  was  of  no  avail.  The  tissues 
were  oedematous  and  little  pus  was  encountered.  The  swelling 
increased  rapidly,  extended  to  the  glands  under  the  jaw  and  met 
underneath  the  chin.  Pain  was  great,  the  patient  was  scarcely 
able  even  to  swallow  liquids.  On  the  sixth  day,  starting  from 
100°,  the  temperature  rose  steadily  to  106.5°  on  the  following 
afternoon.    The  patient  then  died.     (Autopsy  No.  19.) 

All  the  cases  that  I  saw  were  characterized  by  hardness  of  the 
swelling  and  by  extreme  slowness  of  recovery.  Incision  was  re- 
sorted to  in  most  instances  but  the  amount  of  pus  evacuated 
was  always  small. 

Suppurative  Otitis  Media  and  Mastoiditis  were  observed  not 
infrequently.  One  patient  in  the  hospital  on  my  arrival  had 
otitis  media  and  signs  of  meningitis.  He  died  a  few  days  later. 
Lumbar  puncture  showed  an  opalescent  fluid  with  white  floc- 
culi  in  it.  The  diplococcus  of  cerebrospinal  meningitis  was 
looked  for  but  not  found,  neither  were  any  other  bacteria  seen. 
The  case  had  been  diagnosed  as  typhus,  and  probably  correctly, 


156  CLINICAL  OBSERVATIONS 

although  proof  of  it  is  lacking.  Meningitis  is  said  to  be  a  rare 
sequel  of  typhus.  Danielopolu's  ^  observations  on  the  cerebro- 
spinal fluid  are  of  special  interest. 

Another  patient  had  otitis  and  pain  in  the  region  of  the 
mastoid  followed  by  purulent  discharge  from  the  ear.  The 
other  ear  subsequently  became  painful  but  did  not  discharge. 
A  third  patient  had  pain  and  mastoid  tenderness  of  the  same 
character  which  cleared  up  without  discharge  from  the  ear, 
and  a  fourth  had  a  marked  secondary  rise  of  temperature  asso- 
ciated with  pain  on  attempting  to  swallow.  No  abnormality 
could  be  seen  in  the  throat,  but,  after  a  profuse  yellowish 
discharge  had  been  expelled  from  the  mouth,  the  patient  re- 
covered. A  fifth  case  of  typhus,  transferred  to  me  in  conva- 
lescence, had  an  abscess  in  the  neck  originating  in  the  mastoid. 

Paresis  of  the  Hands  was  observed  in  the  case  of  Series  No.  9 
during  convalescence.  Very  little  motion  of  the  fingers  was 
possible,  the  grasp  became  very  weak,  but  improvement  was 
rapid,  and  when  discharged  after  a  protracted  convalescence, 
the  patient  could  use  his  hands  fairly  well.  The  nature  of  the 
condition  is  uncertain. 

Cardiac  Complications,  apparently,  were  not  numerous  al- 
though a  weak  and  rapid  pulse  often  heralded  the  approach  of 
death  several  days  in  advance.  The  rate  and  character  of  the 
pulse,  the  variations  in  blood-pressure  and  the  pathology  have 
already  been  described. 

Acute  endocarditis  is  regarded  as  one  of  the  very  rare  com- 
plications of  typhus.  We  had  two  cases  of  endocarditis  but 
owing  to  the  lack  of  data  regarding  the  early  part  of  the  illness 
when  a  typical  typhus  rash  may  have  been  present,  the  diag- 
nosis of  typhus  remains  in  doubt. 

Autopsy  No.  2  showed  many  large,  recent  vegetations  on  the 
valves.  In  the  case  of  Autopsy  No.  26  the  lesions  were  of  the 
small  verrucous  type  and  there  were  few  of  them. 

Thrombus  formation  in  the  auricles  is  generally  regarded  as 
not  uncommon  in  typhus  so  that  pulmonary  infarction  or 
hemiplegia  might  result.   In  two  of  the  cases  autopsied  by  Dr. 

^  Danielopolu:  loc.  cit. 


Fig.  2.     Three  cases  of  slight  gangrene  following  typhus  fever 


Fig.  1.     Double  parotitis 
Case  of  Autopsy  Number  19 


Fig.  3.     Gangrene  after  typhus 

This  case  is  the  one  shown  on 

the  right  in  Fig.  2 


Photographic  illustrations  of  cases  at  Lady  Paget  Hospital 

{From  photographs  presented  hy  Dr.  Sellards) 


PLATE  XXVI 


TYPHUS  IN  SERBIA  157 

Zinsser  mural  thrombi  were  found  in  the  apex  of  the  left 
ventricle.  These  thrombi  were  believed  to  have  originated 
before  death,  but  of  this  Dr.  Zinsser  was  not  quite  certain. 
(Autopsy  No.  4.) 

Phlebitis  of  a  mild  type  is  believed  to  have  existed  in  the  case 
of  Series  No.  47.  In  the  case  of  Autopsy  No.  8  a  typical  pul- 
monary infarct  was  found. 

Vascular  Complications.  Gangrene  of  the  feet  seems  to  have 
been  very  common  during  the  cold  months  in  the  early  part  of 
the  epidemic.  Dr.  Strong  said  that  he  saw  many  cases  of  gan- 
grene in  some  of  the  hospitals  and  that  in  some  cases  the  nose  or 
ears  were  affected. 

Maitland  ^  made  some  interesting  observations  on  it.  He 
noted  that  before  gangrene  appeared  the  feet  and  hands  be- 
came blue  and  cold  and  the  pulse  "thready,"  i.  e.,  small  and 
weak,  that  red  patches  of  hyperaemia  then  appeared  on  the 
feet,  and  that  gangrene  developed  in  the  areas  which  had  be- 
come thus  congested.  Reasoning  from  the  fact  that  a  part 
once  frostbitten  remains  for  some  time  afterwards  sensitive  to 
exposure  he  inferred  that  frostbite  or  exposure  incidental  to 
warfare  may  have  played  a  predisposing  part  by  injuring  the 
vessels. 

That  this  form  of  gangrene  is  not  embolic  is  evidenced  by  its 
frequent  symmetry.  Moore  ^  believed  that  gangrene  results 
from  arterial  thrombosis,  but  it  seems  probable  that  Maitland 
is  right  in  supposing  that  exposure  may  be  a  factor  in  its  pro- 
duction. Another  factor  which  was  probably  operative  during 
the  early  months  and  particularly  in  some  localities  is  lack  of 
nursing.  The  feet  of  the  patients  may  have  been  allowed  to 
remain  cold  for  long  periods  during  the  illness  when  the  circula- 
tion was  sluggish,  or  the  circulation  may  have  been  handi- 
capped by  leaving  the  boots  on.  In  the  presence  of  some  of 
these  predisposing  factors  local  infection  may  have  aided  in 
the  formation  of  a  thrombus,  or  its  development  may,  per- 
haps, have  been  determined  by  changes  in  the  walls  of  smaller 
arteries  such  as  Prowazek  ^  found  in  those  of  the  skin. 

^  Maitland:  loc.  cit.  ^  Moore:  loc.  cit.  ^  Prowazek:  loc.  cit. 


158  CLINICAL  OBSERVATIONS 

Gangrene  heals  very  slowly.  It  seems  to  develop  most  often 
in  the  later  stages  of  typhus  or  during  convalescence.  Conse- 
quently there  were  many  old  cases  of  it  in  the  wards  when  we 
began  work.  Others  were  brought  in  after  the  rash  had  disap- 
peared. Typical  instances,  slight  in  degree,  are  shown  in  Plate 
XXVI,  Figures  2  and  3. 

Whether  or  not  all  the  cases  of  gangrene  which  we  saw  were 
in  reality  due  to  typhus  it  is  impossible  to  say  with  certainty. 
During  the  summer,  few  cases  of  gangrene  developed  in  the 
hospital  and  none  in  my  wards.  The  comparative  scarcity  of 
gangrene  at  this  period  was  due  apparently  to  two  causes: 
firstly,  warm  weather;  and  secondly,  good  nursing. 

Series  No.  33a  was  brought  in  with  severe  gangrene,  and 
several  other  patients  admitted  at  the  same  time  had  cold,  dis- 
colored feet  which  looked  as  if  about  to  become  gangrenous, 
but  the  circulation  was  restored  by  the  application  of  heat 
locally.  Special  care  was  taken  with  all  typhus  patients  to  keep 
the  feet  warm  and  to  avoid  pressure  upon  them  even  by  the 
blankets. 

Pulmonary  Complications.  Bronchitis  and  passive  conges- 
tion were  so  common  as  to  be  considered  features  of  ordinary 
typhus  rather  than  complications.  Both  were  found  in  most 
of  the  cases  that  came  to  autopsy. 

Pneumonia.  The  dyspnoea  during  life  often  suggested  pneu- 
monia, and  in  cases  of  this  sort  faint  bronchial  breathing  could 
sometimes  be  found  in  the  back,  but  at  autopsy  definite  con- 
solidation was  seldom  discovered. 

There  was  extensive  lobar  consolidation  in  only  one  instance 
(Autopsy  No.  7). 

In  Autopsy  No.  25  bronchopneumonia  was  caused  by  inhala- 
tion of  food. 

Two  probable  cases  of  bronchopneumonia  with  recovery 
were  mentioned  above  under  the  head  of  "Sputum."  (Series 
No.  93.) 

Capricious  localization  of  intense  haemorrhagic  oedema  in 
several  cases  suggested  the,  possibility  that  pneumonia  was  de- 
veloping.   The  condition  in  question  was  found  in  the  case  of 


TYPHUS  IN  SERBIA  159 

Autopsy  No.  18.  It  was  localized  at  the  top  of  the  right  lower 
lobe.  In  this  case  the  ordinary  signs  of  passive  congestion  were 
absent.  In  Autopsy  No.  9  a  similar  condition  existed  at  the 
base  of  the  left  lung,  and  in  Autopsy  No.  20  jt  was  combined 
with  passive  congestion  of  the  ordinary  type. 

Pleuritis.  Extensive  pleuritic  adhesions,  some  old,  some 
more  recent,  and  others  obviously  fresh  were  found  in  many 
cases.  No  typical  friction  rub  was  heard,  but  pleuritis  prob- 
ably accounted  for  some  of  the  pain  in  the  chest  which  was 
complained  of  not  infrequently. 

A  fresh  haemorrhage  was  found  on  the  pleural  surface  of  the 
lung  at  the  right  apex  in  the  case  of  Autopsy  No.  4,  and  in  that 
of  Autopsy  No.  8  there  was  a  recent  infarct. 

Pulmonary  gangrene.  Typical  pulmonary  gangrene  de- 
veloped during  convalescence  in  the  case  of  Series  No.  59  men- 
tioned above  under  '' Respiratory  Signs  and  Symptoms." 

Pulmonary  gangrene  may  be  caused  by  embolism  from  sep- 
tic areas  (Murchison  ^)  or  by  inhalation  of  septic  material 
from  perichondritis  of  the  larnyx  (Curschmann  ^) . 

Renal  Complications.  The  urinary  sediment  during  the 
febrile  period,  in  the  case  of  Series  No.  1,  indicated  nephritis 
by  the  presence  of  many  hyaline,  granular,  and  fatty  casts  and 
compound  granule  cells.  There  was  little  albumen,  however, 
'  and  the  condition  of  the  urine  improved  rapidly  during  conva- 
lescence. A  renal  irritation  of  less  degree,  which  scarcely  re- 
quires to  be  classified  as  a  nephritis,  was  found  in  another  case. 
The  urine  showed  in  this  case  a  specific  gravity  of  1024,  a  trace 
of  albumen,  many  granular  casts,  and  a  few  red  blood-cells. 

In  the  case  of  Series  No.  9  the  urine  was  like  that  in  Series 
No.  1,  but  the  patient  subsequently  developed  oedema  of  the 
face  and  legs,  and  the  nephritis  seemed  to  be  passing  into  a 
chronic  form  when  the  patient  was  discharged. 

In  the  case  of  Autopsy  No.  16  there  was  a  chronic  nephritis 
which  undoubtedly  antedated  the  typhus,  and  there  were  also 
acute  kidney  changes  attributable  to  the  typhus.  This  patient 
died  in  a  convulsion,  probably  of  uraemic  origin. 

^  Murchison:  loc.  cit.  ^  Cvu'schmann :  loc.  cit. 


160  CLINICAL  OBSERVATIONS 

In  a  number  of  other  cases  slight  fatty  degeneration  of  the 
kidney  was  found  at  autopsy.  Curschmann  ^  says  that  most 
authors  regard  acute  nephritis  as  a  comparatively  frequent 
complication  of  typhus.  Among  our  cases  well  marked  evi- 
dence of  nephritis  was  rare,  but  signs  of  more  or  less  renal 
irritation,  such  as  is  common  in  severe  febrile  diseases,  were 
frequently  present. 

XVI.   Convalescence 

Even  after  the  most  severe  symptoms,  convalescence  was 
rapid  considering  the  emaciation  and  weakness  of  the  patients. 
The  gain  of  strength  from  day  to  day,  the  improvement  in  ap- 
pearance, the  increased  ability  to  assimilate  food,  and  the  in- 
crease of  mental  activity  was  rapid  as  compared  with  typhoid. 

Frequently  patients  whose  temperatures  had  not  yet 
reached  normal  would  sit  up  in  bed  and  ask  either  for  solid 
food,  or  to  be  sent  home  on  furlough.  Some  patients  were  fit 
for  discharge  after  a  week  of  normal  temperature.  Those  who 
had  been  very  ill  were  kept  longer  in  the  hospital  because  dis- 
charge often  meant  walking  to  their  homes  which  were,  per- 
haps, many  miles  away. 

Pain,  more  or  less  severe,  in  the  legs  and  feet  was  a  very 
common  symptom  of  convalescence. 

Slight  recurrences  of  temperature  often  terminated  promptly 
after  a  cathartic  had  been  taken. 

In  a  few  cases  rapidity  or  irregularity  of  the  pulse  persisted 
for  a  considerable  time. 

XVI I .   Diagnosis 

The  differential  diagnosis  of  typhus  may  be  discussed  by 
taking  up  the  various  stages  of  the  disease  separately. 

Stage  of  Invasion.  Before  the  appearance  of  the  eruption  in- 
fluenza may  easily  be  mistaken  for  typhus  or  vice  versa  on 
account  of  the  conjunctival  injection,  the  redness  of  the 
pharyngeal  mucous  membrane  and  of  the  tonsils,  and  the  slight 
signs  of  coryza  associated  with  symptoms  of  general  infection. 

^  Curschmann:  loc.  cit. 


TYPHUS  IN  SERBIA  161 

Siebert/  who  studied  typhus  recently  in  a  camp  of  Russian 
prisoners,  says  that  there  were  at  first  mild  illnesses  like  in- 
fluenza, which  were  followed  later  by  cases  of  undoubted  ty- 
phus with  more  severe  symptoms.  He  had  the  impression  that 
among  the  early  influenza-like  cases  there  were  some  cases  of 
abortive  typhus.  Similar  cases  of  mild  typhus  were  observed 
toward  the  end  of  the  typhus  epidemic. 

The  experience  of  Jurgens  ^  among  Russian  prisoners  was 
like  that  of  Siebert.^  He  says  that  just  before  the  typhus  epi- 
demic they  had  influenza  to  deal  with,  but  that  when  the  ty- 
phus appeared  there  was  no  more  influenza. 

During  the  same  epidemic  in  Hungary,  Wiener  ^  observed 
mild  cases  of  typhus  hke  those  described  by  Siebert.^  He  says 
that  the  febrile  period  may  last  from  three  to  six  days  and  that 
the  disease  is  like  influenza  except  that  often  there  are  chills  at 
the  beginning  or  during  the  course  of  the  fever.  In  other  cases 
he  observed  headache,  malaise,  nasal  catarrh  and  cough,  and 
sometimes  angina  from  ten  to  fourteen  days  before  the  out- 
break of  "the  real  disease.". 

Apparently,  influenza  may  prepare  the  way  for  typhus  or 
may  go  with  it  in  the  same  epidemic  as  relapsing  fever  so  often 
does. 

These  observations  are  of  special  interest  to  the  writer  be- 
cause at  the  end  of  the  epidemic  in  Serbia  we  saw  many  cases  of 
transient  fever  which  were  thought  at  first  to  be  influenza,  but 
later,  the  question  of  pappataci  or  "three-day  fever"  was 
raised.  Dr.  Castellani,  who  was  familiar  with  this  disease,  said 
there  were  many  cases  of  pappataci  fever  in  the  town  close  by 
at  that  time. 

The  cases  in  question  at  the  Lady  Paget  Hospital  showed  in- 
jection of  the  conjunctivae,  flushing  of  the  face,  and  catarrh 
of  the  respiratory  passages.  Some  of  them  also  had  transient 
eruptions.  When  first  seen  the  patients  said  they  had  been  ill 
two  days.  They  complained  of  malaise,  headache,  and  pain  in 
the. back  and  limbs.  On  the  third  day,  as  a  rule,  the  tempera- 
ture fell  abruptly  to  normal. 

1  Siebert:  loc.  cit.  ^  Jurgens:  loc.  cit.  ^  Weiner:  loc.  cit. 


162  CLINICAL  OBSERVATIONS 

It  would  seem  that  to  distinguish  between  abortive  cases  of 
typhus,  pappataci  fever,  and  influenza  may  be  extremely  diffi- 
cult because  there  is  no  doubt  that  typhus  infection  may  ap- 
pear in  a  very  mild  form,  and  that  such  cases  are  likely  to 
appear  at  the  beginning  or  end  of  an  epidemic.  It  is  possible, 
therefore,  that  some  of  our  patients  with  supposed  pappataci 
fever  may  really  have  had  abortive  tjrphus.  The  appearance  of 
a  rash  in  several  of  these  cases  strengthens  that  hypothesis. 

The  fact  that  "influenza-like"  bacilli  were  fo^nd  in  the 
sputum  of  two  cases  of  undoubted  typhus,  and  that  in  one  of 
these  cases  they  were  very  numerous  (see  "Respiratory  Signs 
and  Symptoms,"  above),  points  to  the  probable  coexistence 
of  influenza  infection  among  our  patients  at  the  time  when 
the  doubtful  cases  were  developing. 

The  bacilli  in  question  were  described  as  "influenza-like," 
not  because  they  differed  from  the  bacillus  of  influenza  in  size, 
shape,  or  staining  reaction,  but  because  their  identity  was  not 
confirmed  by  cultivation.  The  observations  of  Wiener,^  Sie- 
bert,^  and  Jurgens,^  made  during  the  same  epidemic  of  typhus 
in  another  locality,  increase  the  probability  that  influenza  and 
not  pappataci  fever  may  have  been  the  real  cause  of  some  of 
the  mild  cases  in  question.  If  so,  mild  typhus,  influenza,  and 
pappataci  fever  apparently  prevailed  at  the  same  time.  Series 
Nos.  88  and  100  are  included  to  illustrate  difficulties  of  diag- 
nosis. 

Inasmuch  as  some  epidemics  of  "influenza  or  grippe"  have 
proven  to  be  really  due  to  pneumococcus  bronchitis  still 
another  possible  source  of  error  in  diagnosis  suggests  itself. 
Series  No.  100,  just  mentioned,  was  a  case  of  pneumococcus 
bronchitis. 

Another  important  fact  is  that  influenza  cannot  be  entirely 
excluded  because  of  the  presence  of  an  eruption.  Not  many 
years  ago  in  Paris  an  extensive  epidemic  prevailed  which  was 
finally  diagnosed  as  influenza  although  many  of  the  patients 
had  an  eruption  which  resembled  that  of  typhus  (Wagener  '^) . 

1  Weiner :  loc.  cit.  ^  Jurgens:  loc.  cit. 

-  Siebert:  loc.  cit.  ^  Wagener:  Med.  Klin.,  xv,  No.  25. 


TYPHUS  IN  SERBIA  163 

Relapsing  fever  may  be  confused,  in  the  beginning,  with  the 
stage  of  invasion  of  typhus.  In  typical  cases,  the  onset  of  re- 
lapsing fever  is  more  abrupt  than  in  typhus,  the  temperature 
rises  much  more  rapidly,  goes  higher,  and  the  constitutional 
symptoms  are  slight  in  comparison  with  the  fever.  Conjunc- 
tival injection,  if  present,  is  slight,  but  the  face  may  be  flushed 
and  its  appearance  may  be  strikingly  hke  that  of  typhus.  En- 
largement of  the  spleen  is  easily  demonstrable  in  relapsing  fever. 

Relapsing  fever,  in  a  number  of  cases,  developed  during 
convalescence  from  typhus.   It  may  have  preceded  it  in  others. 

Tertian  malaria  and  aestivo-autumnal  malaria  caused  no 
great  difficulty  in  differential  diagnosis.  These  cases  became 
numerous  as  the  summer  advanced. 

The  onset  of  smallpox  is  said  to  resemble  that  of  typhus. 

Stages  of  Nervous  Excitement  and  of  Nervous  Depression.  The 
presence  of  a  weU-marked  eruption  having  the  usual  distribu- 
tion and  character  of  typhus  was  considered  sufficient  for  a 
positive  diagnosis,  but  when  atypical  rashes  were  seen,  as  in 
Series  Nos.  88  and  100,  it  was  beUeved  that  a  diagnosis  of  ty- 
phus could  not  be  made  with  anything  Hke  certainty.  When, 
also,  the  subsequent  course  of  the  disease  was  atypical  the  'di- 
agnosis remained  in  doubt.  Criteria  based  on  the  degree  of 
severity  of  symptoms  or  on  the  course  of  the  fever  can  have 
little  value  for  recognition  or  exclusion  of  abortive  typhus.  No 
sign  or  symptom  of  typhus  was  nearly  so  characteristic  as  the 
eruption.  When  the  eruption  was  well  developed  the  disease 
ran  a  course  which  varied  little. 

If  there  are  cases  of  typhus  in  which  no  rash  is  present  at  any 
time,  it  would  seem  extremely  difficult  to  diagnose  such  cases 
with  certainty,  even  during  an  epidemic  of  typhus,  because  of 
the  various  other  diseases  that  may  be  prevalent  at  the  same 
time. 

Murchison  ^  says  that  if  there  are  cases  of  typhus  without 
even  a  transient  eruption  they  must  be  very  rare. 

The  diagnosis  of  "typhus  without  eruption"  has  been  made 
not  infrequently  by  some  persons  on  the  ground  that  the  prog- 

1  Murchison :  loc.  cit. 


164  CLINICAL  OBSERVATIONS 

ress  of  the  cases  resembled  typhus  in  other  respects  and  that 
the  patients  were  known  to  have  been  exposed  to  this  infec- 
tion. Having  seen  no  such  case  I  am  skeptical  of  the  diagnosis 
of  'Hyphus  without  eruption." 

If  there  were  cases  of  typhoid  among  my  patients  I  failed  to 
recognize  them  although  this  disease  was  always  borne  in  mind. 
There  should  be  no  difficulty  in  distinguishing  typhoid  from 
typhus  when  the  eruption  is  well  marked  and  typical,  but,  after 
a  transient  or  scanty  eruption  has  disappeared,  doubt  may 
arise. 

Typhus  with  eruption  on  the  face,  as  in  the  case  seen  by  Dr. 
Sellards,  might  bring  measles  into  question.  The  subsequent 
course  of  the  fever  and  the  characteristic  changes  in  the  rash, 
however,  would  soon  settle  the  diagnosis. 

The  Widal  reaction  has  lost  much  of  its  value  for  diagnosis 
since  antityphoid  inoculation  has  become  such  a  common 
practice.  Moreover,  McClure  ^  says  that  a  positive  Widal 
reaction  in  low  dilutions  is  common  in  typhus.  Clumping  oc- 
curred in  a  few  of  our  tjrphus  cases  at  a  dilution  of  1  in  25. 
Agglutination  tests  for  paratyphoid  A  and  B  were  always  per- 
formed with  the  Widal  test.   They  were  uniformly  negative. 

The  bites  of  fleas  and  of  other  vermin,  when  numerous,  may 
resemble  an  eruption,  or  may  confuse  the  picture  when  an  erup- 
tion also  exists.  Similarly,  scabies  may  mask  a  rash  or  even 
lead  to  an  erroneous  diagnosis  of  typhus  fever.    (Series  No.  33.) 

The  case  of  Series  No.  88  presents  a  particularly  complex 
combination  of  skin  lesions.  Drug  eruptions,  a  profuse  crop  of 
rose  spots  in  typhoid,  haemorrhagic  eruptions  in  the  acute  ex- 
anthemata and  skin  lesions  in  secondary  syphilis,  plague  or 
influenza  may  require  to  be  differentiated  from  typhus.  The 
spots  of  purpura,  cerebrospinal  meningitis  or  acute  endo- 
carditis are  not  likely  to  cause  difficulty. 

The  association  of  scurvy  with  typhus,  which  has  been  ob- 
served in  some  epidemics,  and  the  possibility  of  combined 
infection  of  typhus  with  typhoid,  dysentery,  diphtheria,  re- 
lapsing fever,  or  the  exanthemata  should  be  borne  in  mind. 

1  McClure:  Handbook  of  Fevers,  N.  Y.,  1914,  p.  321. 


TYPHUS  IN  SERBIA  165 

Stage  of  Defervescence.  Diagnosis  at  this  stage  depends  on  the 
exclusion  of  typhoid  fever,  relapsing  fever,  tuberculosis,  ma- 
laria, and  Malta  fever,  of  which  we  had  two  probable  cases, 
and  on  the  presence  of  reasonably  characteristic  remains  of  the 
eruption.  The  recognition  of  this  was  discussed  in  the  section 
on  ^^Skin." 

At  this  stage,  also,  acute  endocarditis  may  come  into  ques- 
tion because  heart  murmurs  are  generally  present  in  the  later 
stages  of  typhus.  The  cases  of  Autopsy  Nos.  2,  11,  and  26  illus- 
trate the  difficulties  of  late  diagnosis. 

When,  during  a  typhus  epidemic,  a  patient  is  brought  in  with 
gangrene  of  the  leg  (Series  No.  33a),  or  with  parotitis  following 
a  fever  of  many  days  duration,  it  is  probable  that  the  lesions 
are  sequelae  of  typhus;  but,  whereas  they  develop  sometimes 
also  in  other  infectious  diseases  a  diagnosis  can  scarcely  be 
made  with  certainty  in  cases  of  this  sort  after  the  rash  has 
disappeared. 

XVIII.    Treatment  in  General 

As  a  basis  for  rational  treatment  the  causes  of  morbidity  and 
of  mortality  require  to  be  understood. 

It  is  certain  that  filth,  famine,  overcrowding,  and  lack  of 
ventilation  favor  the  spread  of  typhus.  They  favor  it  not  only 
by  increasing  opportunity  for  transmission  of  infection  but 
also  by  weakening  in  advance  the  resistance  of  the  person  in- 
fected. Notwithstanding  some  apparently  contradictory  evi- 
dence, it  seems  certain  that  bad  conditions  of  living  tend  to 
lower  the  resistance  of  the  individual  and  to  increase  morbidity 
as  well  as  mortality  in  an  epidemic  of  typhus. 

The  first  fundamental  principle  of  treatment  rests  on  these 
facts.  It  demands  maintenance  of  the  patient's  remaining 
strength  by  every  possible  means  (1)  by  removal  from  unsanitary 
surroundings  (2)  by  good  nursing,  and  (3)  by  a  well-regulated 
diet.   These  points  are  elaborated  below.- 

Fresh  air  and  cleanliness  are  certainly  beneficial.  It  is  prob- 
able, therefore,  that  suitable  tents  would  make  better  wards 
than  ill-ventilated  rooms.    Maxwell  ^  says  that  the  Italians  in 

1  Maxwell:  Brit.  Med.  Jour.,  1915,  No.  1,  p.  52'8. 


166  CLINICAL  OBSERVATIONS 

Tripoli  preferred  to  use  tents  or  huts  for  the  sake  of  ventilation 
and  ease  of  destroying  vermin. 

Good  nursing  saves  the  patient  needless  suffering,  and  helps 
very  much  to  maintain  strength. 

It  is  probable  that  parotitis,  ulcerative  lesions  of  the  mouth 
and  throat,  otitis  media,  and  external  infectious  processes  in- 
cluding bedsores  can  be  prevented  in  most  cases  by  a  skillful 
nurse  if  she  has  sufficient  time  to  do  her  work  thoroughly;  and 
that  hypostatic  congestion,  pulmonary  complications,  and  gan- 
grene of  the  extremities  will  be  far  less  common  among  her 
patients  than  among  those  lacking  such  care. 

The  kind  and  quantity  of  nourishment  should  be  suited  to 
the  digestive  capacity  of  the  individual  and  must  vary  with  the 
stage  of  the  illness  and  the  nature  of  the  symptoms.  The  effort 
should  always  be  made  to  administer  the  greatest  quantity  of 
nourishment  that  the  patient  can  digest.  Liquid  nourishment 
only  can  be  taken  by  the  sicker  patients,  but  when  soft  solids 
can  be  taken  they  should  be  administered.  Good  judgment  is 
needed  to  get  the  best  results.  Therefore  the  physician  should 
personally  supervise  the  dietary. 

The  methods  advocated  above  are  important  not  only  to 
combat  pre-existing  weakness  in  cases  admitted  late  in  the  dis- 
ease, but  also  to  counterbalance  the  exhaustion  and  loss  of 
flesh  incidental  to  typhus  in  its  severer  forms.  Prostration  is 
more  often  extreme  in  typhus  than  in  any  other  similar  dis- 
ease. A  most  striking  fact  is  the  occurrence  of  many  deaths 
after  the  period  of  defervescence  even  when  severe  comphcations 
have  not  developed.  It  is  probable  that  extreme  exhaustion, 
with  attendant  depression  of  vital  functions  and  consequent 
inability  to  recuperate,  is  the  essential  factor  in  the  fatal  result 
in  most  of  these  cases  (Autopsy  Nos.  13  and  14).  That  exhaus- 
tion is  also  an  important  factor  in  many  deaths  which  occur 
during  defervescence,  and  in  some  that  occur  still  earlier,  seems 
extremely  probable  (Autopsy  Nos.  9  and  24), 

Maintenance  of  strength,  therefore,  seems  to  be  important  at 
all  stages  of  typhus  as  a  means  of  saving  life.  That  this  prin- 
ciple is  of  special  importance  for  the  treatment  of  middle-aged 


TYPHUS  IN  SERBIA  167 

or  elderly  patients  is  suggested  by  statistics  of  mortality.  It  is 
known  that,  after  the  period  of  childhood,  percentage  mor- 
tality increases  steadily  with  advance  in  years,  and  that  it 
becomes  extremely  high  in  elderly  persons.  Murchison's  ^ 
Diagram  II  based  on  more  than  18,000  cases  demonstrates  the 
truth  of  this  statement. 

It  is  not  possible  to  determine  the  stage  of  the  disease  at 
which  death  occurred  in  all  of  our  cases  which  were  autopsied 
but  more  than  a  third  of  the  fatalities  (seven  at  least)  occurred 
after  defervescence  from  the  primary  fever.  In  at  least  five  of 
these  cases  the  dominant  factor  seemed  to  be  exhaustion. 
Death  in  the  sixth  case  was  from  parotitis  and  sepsis,  and  in 
the  seventh  case  from  exhaustion  and  pneumonia.  In  three 
of  the  earlier  deaths  exhaustion  seemed  to  play  an  important 
part  (Autopsy  Nos.  6,  9,  and  24). 

Inasmuch  as  a  large  proportion  of  patients  die  after  having 
passed  the  acute  period  of  typhus  it  is  clear  that  efforts  to  con- 
serve strength  should  not  be  relaxed  until  after  the  patient  has 
made  decided  improvement. 

Nasal  feeding  was  used  in  several  patients  who  were  unable 
or  unwilling  to  swallow  enough  food.  It  served  well  in  several 
cases  that  might  not  have  recovered  otherwise.  Unfortunately, 
one  delirious  patient,  who  struggled  against  the  feedings  and  in 
whose  case  they  were  tried  as  a  last  resort,  developed  inhala- 
tion pneumonia. 

The  place  of  alcohol  in  the  treatment  of  typhus  is  an  impor- 
tant question. 

When  a  patient  is  rapidly  losing  strength  because  he  cannot 
assimilate  food,  I  believe  that  alcohol  should  be  administered, 
not  in  small  doses,  but  freely.  Alcohol  has  been  abused  in  the 
past,  and  many  now  deny  that  it  has  any  value,  but  they  are 
probably  mistaken. 

In  suitable  cases  alcohol  acts  apparently  as  a  food  which  is 
readily  absorbed,  and  capable  to  a  considerable  degree  of  re- 
placing other  nourishment.  If  this  is  true,  it  is  important  that 
the  indications  for  administering  alcohol  should  be  clearly 
understood. 

1  Murchison:  loc.  cit. 


168  CLINICAL  OBSERVATIONS 

Gerhard^  on  the  subject  of  typhus  says:  —  ''In  the  later 
stages  of  fever,  wine,  porter,  and  in  a  few  cases  even  brandy 
were  given  with  much  benefit.  It  is  difficult  to  conceive  the 
extreme  prostration  in  which  our  patients  were  left  after  a 
severe  attack  of  fever.  The  skin  is  usually  cool  and  the  pulse 
weak  and  fluttering,  but  there  is  still  muttering  delirium  and 
great  feebleness.  Under  these  circumstances,  wine,  combined 
with  quinine,  and  a  nutritious  diet  produced  an  effect  which 
was  almost  magical."  "The  amount  of  wine  given  in  twenty- 
four  hours  varied  from  4  to  16  ounces.  It  was  generally  from  6 
to  8  ounces.  Practitioners  have  remarked  that  a  moderate 
dose  of  wine  is  capable  of  producing  all  the  good  effects  which 
can  result  from  it.  In  our  observations  a  similar  result  was  ob- 
tained, and  we  rarely  exceeded  eight  ounces  daily  except  as  a 
temporary  prescription  to  obviate  extreme  prostration.  The 
quantity  given  with  that  object  was  not  limited  but  was  increased 
until  the  strength  of  the  patient  improved.''  ''Where  the  fever 
was  higher  and  the  prostration  less,  wine  became  less  useful. 
We  therefore  restricted  its  employment  to  the  periods  of  prostration, 
when  it  was  indispensably  necessary."    (The  italics  are  mine.) 

Stokes  ^  taught  that  where  there  was  f aintness  of  the  heart 
sounds  at  the  apex  and  weakening  of  the  cardiac  impulse  with  a 
pulse  which  was  rapid  and  of  poor  quality,  alcohol  was  re- 
quired; but  he  took  into  consideration  also  the  state  of  nutri- 
tion of  the  patient.  Two  cases,  described  by  him  in  Chapter 
XXVIII  of  his  book,  show  that  he  used  alcohol  very  freely  in 
the  presence  of  extreme  prostration  and  emaciation.  He  ad- 
vises against  its  free  use  when  there  is  "active  irritation  of  the 
brain,"  but  says  that  alcohol  may  be  tried  even  then  if  cir- 
cumstances demand. 

Murchison  ^  complained  of  the  indiscriminate  use  of  alcohol 
common  in  his  day  and  doubted  the  wisdom  of  administering 
more  than  twelve  ounces  of  brandy  in  twenty-four  hours  under 
any  circumstances,  but  he  valued  alcohol  too.  He  says  that 
most  patients  over  forty  are  benefited  by  alcohol  from  the  com- 
mencement of  the  second  week  or  earlier,  that  persons  of  in- 

1  Gerhard :  loc.  cit.  ^  Stokes:  loc.  cit.  ^  Murchison:  loc.  cit. 


TYPHUS  IN  SERBIA  169 

temperate  habits  require  alcohol  earlier  and  in  greater  quantity 
than  others,  that  the  chief  indication  for  the  use  of  alcohol  is  de- 
rived from  observation  of  the  pulse  and  heart  as  stated  by  Stokes, 
and  that  the  more  the  typhoid  state  is  developed  the  more  will  al- 
cohol be  needed.  Slowing  of  the  pulse  under  alcohol  and  dim- 
inution of  delirium  were  regarded  as  evidence  of  beneficial 
effect  and  vice  versa.  Other  indications  for  alcohol  were  cold- 
ness of  extremities  and  a  dry,  brown  tongue.  Profuse  perspira- 
tion without  contemporaneous  improvement  indicated  a  need 
for  more  alcohol,  and  a  hot,  dry  skin  or  scantiness  of  the  urine 
were  considered  as  contra-indications  for  alcohol. 

The  question  of  whether  alcohol  was  a  food  or  a  stimulant 
troubled  Murchison  ^  and  he  concluded  to  call  it  a  stimulant. 

Indications  for  the  use  of  alcohol  in  typhoid  fever  were  given 
by  F.  C.  Shattuck  ^  as  follows:  —  "If  the  heart  shows  distinct 
signs  of  undue  weakness,  if  hypostasis  is  threatened  or  marked, 
if  the  power  to  take,  retain,  or  appropriate  nourishment  is 
unduly  lowered,  I  believe  it  to  be  a  grave  error  in  judgment  to 
withhold  alcohol."  If  alcohol  is  useful  in  typhoid  it  is  needed 
more  often  for  the  same  indications  in  severe  typhus. 

Dr.  F.  C.  Shattuck  has  taught  that  "in  acute  infections, 
especially  toward  their  later  stages,  the  toleration  of  alcohol  may  be 
greatly  increased  over  that  of  health,  and  that  it  may  then  render 
inestimable  service,  notably  when  the  power  of  taking  or  assimilat- 
ing food  is  greatly  impaired.  No  measured  limit  can  be  set 
down  for  its  use.  No  more  should  be  given  than  is  burnt  up, 
combustion  being  determined  by  the  presence  or  absence  of  the 
smell  of  alcohol  on  the  breath,  in  combination  with  the  symp- 
toms of  the  patient,  and  the  influence  upon  the  latter  appar- 
ently exerted  by  the  alcohol." 

To  discuss  experimental  evidence  as  to  the  effect  of  alcohol 
on  nutrition,  circulation,  respiration,  etc.,  would  be  out  of  place 
in  this  paper  but  a  few  facts  may  be  stated.  It  is  well  known 
that  a  certain  quantity  of  alcohol  is  quickly  absorbed,  and 
readily  oxidized  in  the  healthy  body,  that  it  can  supply  some  of 

1  Murchison:  loc.  cit. 

^  Shattuck,  F.  C. :  Therapeusis  of  Internal  Diseases,  Forchheimer,  N.  Y.,  1913,  ii. 


170  CLINICAL  OBSERVATIONS 

the  energy  ordinarily  derived  from  carbohydrate  or  fat,  and 
that,  in  so  doing,  it  prevents  the  destruction  of  body  tissue 
which  ensues  when  the  quantity  of  fat  or  carbohydrate  ingested 
is  insufficient  for  requirements.  Less  is  known  of  its  action  in 
disease  of  various  kinds. 

It  is  reasonable  to  suppose,  however,  that  the  beneficial 
effects  of  alcohol  in  ill-nourished  patients  are  due  in  large 
measure  to  energy  supplied  by  the  alcohol,  and  that,  when  the 
patient  is  exhausted  and  emaciated,  alcohol  by  acting  as  a  food 
may  increase  vital  energy  and  thus  indirectly  improve  circula- 
tion and  respiration.  It  is  the  experience  of  Dr.  F.  C.  Shat- 
tuck,  as  stated  above,  that  conditions  may  occur  in  disease 
which  greatly  increase  the  power  to  assimilate  alcohol. 

Patients  under  my  care  received  alcohol  in  considerable 
quantities  and  apparently  with  benefit.  It' may,  at  least,  be 
said  that  no  typhus  patient  died  in  my  wards  after  the  period  of 
high  fever  except  from  severe  complications. 

The  earlier  the  stage  of  t3rphus,  the  less  prominent  seems  to 
be  exhaustion  as  a  cause  of  death.  It  may,  however,  be  an 
important  factor  in  exceptional  cases  as  it  seems  to  have  been  in 
the  case  of  Autopsy  No.  9. 

The  principal  cause  of  early  death  when  it  occurs  in  typhus 
is  toxaemia.  There  may  be  lesions  in  the  heart  and  other  or- 
gans, but  severe  functional  disturbances  without  corresponding 
known  lesions  seem  to  be  the  direct  result  of  toxins  circulating 
in  the  blood.  Some  of  the  older  writers  have  denied  that  cere- 
bral congestion  and  oedema  are  the  cause  of  cerebral  symp- 
toms, claiming  that  these  occur  to  the  same  degree  in  cases  in 
which  cerebral  symptoms  were  not  marked,  and  that  the 
excess  of  fluid  merely  replaces  atrophy  of  brain  tissue.  Quite 
different  views  have  been  expressed  by  Danielopolu  ^  in  his 
recent  book  on  typhus.    More  light  is  needed  on  this  question. 

The  second  fundamental  principle  in  the  treatment  of  typhus 
is  based  on  the  belief  that  toxaemia  is  an  important  cause  of 
death  and  that,  therefore,  it  should  be  combated  in  every  pos- 
sible way. 

^  Danielopolu:  loc.  cit. 


TYPHUS  IN  SERBIA  171 

Toxaemia  in  typhus  can  be  attacked  by  attempting  to  dilute 
the  toxin  in  circulation,  by  promoting  its  elimination,  or,  ac- 
cording to  Danielopolu,^  by  neutralizing  or  destroying .  the 
toxin  in  the  blood  by  means  of  intravenous  injections  of 
chlorinated  salt  solution.  This  last  method  was  unknown  when 
this  paper  was  originally  written. 

Circulating  toxin  can  be  diluted  by  the  administration  of 
abundant  water  by  mouth.  When  sufficient  water  cannot  be 
ingested  it  can  be  given  in  the  form  of  enemata,  or  as  salt 
solution  by  hypodermatoclysis  or  intravenously.  These  meth- 
ods were  used  freely. 

They  caused  marked  increase  in  the  excretory  activity  of  the 
kidneys  and  seemed  also  to  improve  the  circulation.  Thus, 
they  may  have  benefited  the  patient  by  diluting  toxin  and  by 
favoring  its  elimination  through  the  kidneys  both  directly  and 
indirectly. 

The  question  of  how  much  liquid  should  be  ingested  by  the 
patient  daily  in  acute  fevers  has  not  been  settled.  McCrae^ 
advocates  three  liters  per  diem  as  a  minimum  in  typhoid,  prefers 
five  or  six  liters,  and  has  administered  much  larger  quantities.  It 
may  be  asked  whether  this  internal  hydrotherapy,  when  carried 
to  extremes,  may  not  cause  disturbances  which  more  than 
counterbalance  its  benefits.  For  ex-ample,  may  it  interfere 
with  digestion?  May  it  put  undue  strain  on  the  heart  in  cases 
in  which  the  heart  is  weak?  May  it,  in  typhoid,  increase  the 
frequency  or  severity  of  intestinal  haemorrhage? 

In  typhus  the  possible  danger  of  overtaxing  the  heart  by 
rapidly  administering  very  large  quantities  of  fluid  should  be 
borne  in  mind  because  the  heart  muscle  seems  more  often  to  be 
weak  in  typhus  than  in  typhoid  fever.  On  the  other  hand, 
damage  to  the  heart  and  blood-vessels  might  be  minimized  by 
ingestion  of  large  amounts  of  liquid  if  begun  early  in  the  disease. 

The  bowels  should  receive  special  attention  in  typhus,  a  dis- 
ease in  which  constipation  is  the  rule,  in  order  to  prevent 
absorption  of  toxins  from  them.  Slight  recurrences  of  fever 
in  convalescence  frequently  yield  promptly  to  free  catharsis. 

'  Danielopolu:  loc.  cit.  ^  McCrae:  Modern  Medicine,  ed.  by  Osier,  Phil.,  1907. 


172  CLINICAL  OBSERVATIONS 

When,  in  typhus,  the  face  becomes  cyanotic,  the  breathing 
rapid,  and  signs  of  general  toxaemia  are  well  marked  it  seems 
probable  that  moderate  purgation  with  a  saHne  cathartic,  such 
as  magnesium  sulphate,  may  have  a  beneficial  effect.  There  is 
a  striking  resemblance  between  some  of  these  cases  and  certain 
instances  of  influenza  with  bronchopneumonia  which  were 
treated  in  France  in  the  autumn  of  1918.  Purgation  seemed  in 
these  cases  of  bronchopneumonia  to  be  definitely  beneficial. 
Whether  the  improvement  resulted  from  ehmination  of  toxic 
material  or  otherwise  is  uncertain.  It  may  have  benefited  the 
heart  by  reducing  the  volume  of  the  circulating  fluid. 

XIX.   Symptomatic  Treatment 

Among  symptoms  of  a  serious  nature  in  our  cases  of  typhus 
were  those  of  circulatory  insufficiency.  This  condition  seemed 
to  be  the  contributing  cause  of  death  in  most  of  the  fatal  cases. 
Less  often  it  was  regarded  as  the  principal  cause  of  death. 

Digitahs  was  administered  in  all  cases  in  which  the  pulse  be^ 
came  weak  and  irregular  or  the  pulse  rate  rose  above  120  per 
minute.  The  dose  by  mouth  varied  from  0.2  to  0.4  gram  daily. 
In  several  instances  bradycardia  was  thought  to  have  been 
caused  by  the  digitahs  (Series  No.  83).  It  seems  impossible  to 
tell  whether  or  not  the  patients  would  have  done  as  well  with- 
out the  digitalis. 

A  number  of  patients  had  occasional  sudden  attacks  of  cir- 
culatory weakness  from  which  they  rallied  promptly  after 
administration  of  whisky  by  mouth,  a  drink  of  hot  tea  or  soup, 
or  a  subcutaneous  injection  of  strychnin,  camphor  in  oil,,  or 
ether.  During  these  attacks  the  patients  seemed  to  be  in  an 
alarming  state  of  coUapse.  The  pulse  was  extremely  weak  or 
even  imperceptible.  The  recovery  was  prompt  and  striking. 
One  patient  recovered,  however,  before  anything  had  been  ad- 
ministered, so  that  doubt  is  cast  on  the  value  of  the  treatment 
used  for  the  others.  The  patient  referred  to  in  Autopsy  No.  24 
had  many  such  collapses  before  he  died. 

I  am  not  prepared  either  to  attach  much  value  to  these 
methods  of  cardiac  stimulation  or  to  deny  them  all  value,  but 


TYPHUS  IN  SERBIA  173 

incline  to  the  belief  that  they  may,  in  some  cases,  produce 
transient  reflex  rise  of  blood-pressure  which  may  have  a  tem- 
porary beneficial  effect.  For  example,  we  know  that  pain  causes 
a  temporary  rise  of  blood-pressure.  A  subcutaneous  injection, 
therefore,  may  act  through  pain  even  if  the  substance  injected 
is  medicinally  inert.  Locally  irritating  substances  like  camphor 
or  ether  probably  act  mainly  in  this  way. 

As  a  heart  stimulant  strychnin  has  no  demonstrated  value. 
It  was  not  used  by  me  for  this  purpose.  The  work  of  Richard 
C.  Cabot  and  the  more  recent  studies  of  Newburgh  ^  throw 
light  on  this  subject. 

When  a  patient  had  had  one  attack  of  circulatory  collapse  it 
was  found  that  another  might  be  expected  to  follow.  The  na- 
ture of  circulatory  insufficiency  in  typhus  has  already  been 
discussed  under  "Pathology  of  the  Circulatory  System "  where 
reasons  were  given  for  believing  that  the  disturbance  originated 
sometimes  in  the  vascular  system  and  sometimes  in  the  heart. 
More  often,  apparently,  the  two  kinds  of  disorder  were  com- 
bined. 

Salt  solution  was  administered  intravenously  in  a  number  of 
cases  of  different  types.  In  the  cases  in  which  the  circulatory 
disturbance  seemed  to  be  mainly  due  to  vascular  relaxation  the 
response  was  gratifying. 

In  the  case  of  Series  No.  9  the  circulation  improved  re- 
peatedly after  the  infusions,  and  life  seems  to  have  been  pro- 
longed by  them  for  several  days  until  a  favorable  turn  of  the 
illness  was  followed  by  recovery. 

Salt  solution  by  intravenous  infusion  was  used  also  in  the 
cases  of  Series  Nos.  10,  59,  and  93,  and  in  the  cases  described 
under  Autopsy  Nos.  24  and  25.  In  the  case  of  Series  No.  10  the 
infusion  gave  little  benefit.  During  the  second  injection  tem- 
porary improvement  of  the  pulse  was  followed  by  signs  of 
heart  weakness  which  made  it  necessary  to  stop  the  procedure. 
A  slight  rigor  followed  soon  after  the  injection.  Infusions  were 
used  in  the  case  of  Series  No.  59,  not  to  improve  the  pulse, 
which  was  fairly  good,  but  to  replace  fluid  lost  by  diarrhoea 

1  Newburgh:  Am.  Jour.  Med.  Sc,  1915,  xlix,  696;  Arch.  Int.  Med.,  1915,  xv,  458. 


174  CLINICAL  OBSERVATIONS 

and  to  prevent  expected  circulatory  collapse.  The  first  injec- 
tion did  good.  The  second  was  soon  followed  by  transient 
weakness  and  irregularity  of  the  pulse.  This  time  the  solution 
may  have  done  more  harm  than  good.  In  the  case  of  Series  No. 
93  two  infusions  were  given.  Both  were  followed  by  rigors. 
Nevertheless,  even  in  this  case,  the  effect  on  the  whole  may 
have  been  beneficial.  After  the  rigors  were  over  the  patient's 
condition  was  more  satisfactory  than  it  had  been  before  the 
infusion  was  administered. 

In  the  case  of  Autopsy  No.  24  the  first  infusion  caused  a 
marked  temporary  improvement  in  the  circulation  but  tran- 
sient violent  delirium  followed,  and,  later,  another  circulatory 
collapse  occurred.  A  second  infusion  given  several  hours  after- 
wards called  forth  little  circulatory  response.  This  case  seemed 
to  be  one  of  the  sort  which  is  hopeless  from  the  beginning. 

Autopsy  No.  25  is  a  somewhat  similar  case.  Salt  solution 
improved  the  pulse  in  this  case  but  delirium  increased  and  a 
rigor  took  place.  After  the  second  infusion,  morphine  was  in- 
jected, no  rigor  occurred,  and  the  pulse  remained  satisfactory  for 
twenty-four  hours  after  administration  of  the  salt  solution. 

The  cause  of  the  rigors  which  so  often  followed  infusions  of 
salt  solution  in  my  cases  is  not  clear.  Apparently,  they  were  not 
due  to  errors  of  technique  because  they  were  not  prevented  by 
the  most  careful  preparation  of  the  solution,  by  using  freshly 
distilled  water,  or  by  carefully  maintaining  a  warm  tempera- 
ture of  the  solution  while  it  was  being  administrated. 

It  is  of  special  interest  that  Castelloi  (quoted  by  Doty  ^) 
administered  normal  salt  solution  several  times  daily  in  the 
dose  of  250  to  300  c.c.  totalling  from  600  to  1800  c.c.  per  day 
in  136  cases;  and  that  he  had  only  9  deaths  under  this  regime 
as  against  13  deaths  in  113  patients  under  "purely  symp- 
tomatic treatment." 

Sponge  baths  served  to  reduce  temperature,  but  no  very  cer- 
tain benefit  resulted. 

When  there  was  marked  pulmonary  congestion  and  bron- 
chitis no  form  of  treatment  seemed  to  relieve  the  patient.   It  is 

^  Doty:  loc.  cit. 


TYPHUS  IN  SERBIA  175 

difficult  to  see  what,  beyond  general  measures,  can  be  done  for 
such  cases.  The  frequently  existing  acute  inflammation  of  the 
bronchial  mucosa  would  seem  to  contra-indicate  the  use  of 
'^stimulating"  expectorants.  Atropine  might  be  expected  to 
make  the  condition  worse  by  increasing  the  viscidity  of  the 
secretion  and  thus  preventing  its  expulsion.  The  associated 
bronchitis,  when  severe,  contra-indicates  morphine  because  it 
prevents  expectoration. 

The  urine  should  be  watched  for  signs  of  nephritis  and  ap- 
propriate modifications  of  diet  should  be  instituted  when  there 
is  evidence  of  nephritis. 

The  stools  should  be  inspected,  especially  when  there  is 
diarrhoea,  to  see  if  the  food  is  being  well  digested.  Curds  of 
undigested  milk  are  a  frequent  cause  of  diarrhoea  in  tjrphoid 
fever. 

The  prevention  of  complications  was  spoken  of  above  under 
' '  Treatment  in  General ' '  and  nursing.  Special  attention  should 
be  paid  to  the  mouth  and  throat.  The  legs  and  feet  should  be 
kept  warm,  and  pressure  on  the  feet,  even  from  the  bedclothes, 
should  be  avoided  lest  it  contribute  to  the  production  of 
gangrene. 

At  first  sight  the  treatment  for  gangrene  of  the  toes  might 
seem  to  be  amputation,  but  Dr.  Smith  informed  me  that,  even 
when  amputation  was  performed  rather  high,  the  gangrene 
sometimes  recurred.  When  the  gangrene  was  not  extensive  he 
preferred  to  keep  his  patients  in  bed  and  to  wait  for  recovery  by 
spontaneous  separation  of  the  dead  tissue.  The  process  was 
slow  but  loss  of  substance  was  surprisingly  small  and  the  re- 
sults were  excellent.  When  pieces  of  bone  had  been  exposed 
they  sloughed  off  and  the  skin  grew  over  the  stumps. 

It  seems  possible  that  pituitrin  might  be  useful  in  cases  of 
circulatory  collapse  in  typhus.   Having  none  it  was  not  tried. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


INDEX  OF  ILLUSTRATIVE   CASES 


(a)  Typhus  Fever,  Recovery 
Series  Number    1 177 


9. 
10. 
36. 
48. 
49. 
57. 
59. 
60. 
61. 
83. 
92. 
93. 


181 
185 
188 
188 
190 
192 
195 
198 
199 
200 
202 
204 


(6)  Typhus  Fever,  Fatal.     Autopsy 
Autopsy  Number    4 208 


5. 

6. 

7. 

8. 

9. 
10. 
12. 
13. 


208 
209 
209 
210 
211 
211 
212 
213 


Autopsy  Number  14 214 


16 

214 

17 

215 

18 

216 

19 

218 

20 

220 

21 

222 

22 

223 

23 

223 

24. 226 

25 

229 

(c)  Typhus  Fever,  Fatal.    No  Autopsy 

Series  Number  87 232 

21 233 

(d)  Problems  in  Diagnosis 

Autopsy  Number    2 235 

11 235 

26 235 

Series             "         33 236 

33a 237 

"                "        88 238 

100 240 


Series  Number  1.  Diagnosis:  Typhus  fever,  moderately 
severe;  with  mild  acute  nephritis. 

Clinical  Notes 

Austrian  prisoner,  age  30,  working  as  a  mason,  admitted  to  the  hospital 
on  April  23. 

April  24-  Present  Illness:  For  three  days  fever,  constipation,  and  loss  of 
appetite.  No  vomiting.  Pain  in  the  eyes  began  early  and  persists.  Deaf- 
ness in  the  right  ear  began  yesterday.  There  is  no  coryza  or  sore  throat. 
Bowels  moved  four  times  last  night  after  calomel.  There  is  pain  in  the  left 
knee  and  calf,  but  none  in  the  back. 

177 


178  CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

Physical  Examination:  The  patient  is  well  developed  and  nourished. 
There  is  a  bright  flush  over  the  malar  region  and  a  slight  suffusion  of  the 
eyes.  The  tongue  is  moist  and  shows  a  moderately  heavy  white  coat.  The 
throat  is  negative.  There  is  no  glandular  enlargement. 

Heart:  Dulness  not  increased,  action  rapid,  rate  92.  The  pulmonic 
second-sound  is  louder  than  the  aortic  second-sound.  The  first-sound  at  the 
apex  is  indistinct.  A  soft  systolic  murmur  is  heard  in  the  puhnonic  area. 
The  pulse  is  large  and  bounding,  the  vessel  walls  soft,  and  the  blood-pres- 
sure, II5/S.-0O/D. 

Lungs:  Negative. 

Abdomen:  Full  and  soft,  not  sensitive  to  pressure. 

Liver  and  Spleen:  Not  palpable,  but  the  splenic  dulness  is  increased. 

Reflexes:  The  right  abdominal  is  present,  but  that  on  the  left  is  in- 
definite.   The  knee-jerks  are  present. 

Calf  Muscles  are  sensitive  to  pressure. 

The  Eruption  consists  of  pink  macules  varying  in  size,  irregular  in  shape, 
disappearing  on  pressure,  profusely  and  uniformly  distributed  over  the 
trunk,  legs,  and  arms.  A  few  are  seen  on  the  backs  and  soles  of  the  feet. 
The  hands  and  the  face  are  free  from  spots.  There  are  some  bright  pink 
spots  on  the  scalp. 

April  25.  The  eruption  seems  more  profuse  on  the  body  and  some  spots 
no  longer  disappear  on  pressure.  The  general  color  of  the  rash  is  purplish. 
Spots  have  appeared  on  the  backs  of  the  hands. 

The  mind  is  clear,  and  the  expression  phlegmatic.  In  the  afternoon  the 
patient  vomited  some  greenish  fluid  and  had  pain  in  the  abdomen.  The 
bowels  moved  three  times  today.  The  coat  on  the  tongue  has  become  yel- 
lowish. There  is  no  cough.  The  abdomen  is  soft  and  not  sensitive.  Haemo- 
globin (Tallquist),  95  per  cent.  White  count,  24,000.  Urine:  normal  in 
color,  acid,  sp.  gr.  1016,  albumen  a  trace,  no  sugar,  diazo-reaction  present. 
Sediment:  coarse  granular  casts. 

April  26.  The  eruption  is  clearly  visible  on  the  pahns  of  hands.  Many 
spots  on  the  body  are  still  pink  and  disappear  on  pressure.  A  few  others 
have  begun  to  turn  brown.  The  mind  is  clear  and  the  expression  brighter. 

April  27.  Mentally  duller  today:  complains  of  weakness,  heaviness  in 
the  head  and  pain  over  the  eyes.  Slight  Kernig's  sign  present.  Attempt  to 
flex  neck  does  not  cause  pain  but  the  neck  is  slightly  stiff.  The  pupils  are  of 
normal  size. 

The  Calf  Muscles  are  slightly  sensitive  to  firm  pressure. 
The  Sputum  is  viscid  and  frothy  with  yellowish  streaks. 
Urine:  A  24-hour  mixed  specimen  is  light,  but  slightly  smoky  in  color, 
acid,  sp.  gr.  1015,  albumen  a  slight  trace,  no  sugar,  diazo-reaction  positive. 
Tests  for  acetone  or  diacetic  acid  were  negative.   The  sediment  shows  many 
granular  casts.  The  quantity  of  urine  has  increased. 


GASES  OF  TYPHUS  FEVER  WITH  RECOVERY    179 

April  28.  Blood:  White  count,  12,000;  haemoglobin  (SahH),  120  per  cent, 
(Tallquist),  100  per  cent;  red  count,  4,000,000;  color  index,  1.75;  differential 
count: — polymorphonuclears,  92  per  cent,  large  mononuclears,  4  percent, 
other  types,  4  per  cent.  The  red  cells  appear  normal.  The  platelets  are 
scarce. 

Heart:  The  sounds  are  rather  feeble.  The  first-sound  is  short.  The 
blood-pressure  is  65/S.-50/D. 

The  tongue  is  dry,  and  the  face  bronzed  and  dusky.  There  is  moderate 
loss  of  flesh.  The  eruption  is  purple  and  brown.  The  patient  is  drowsy  but 
his  mind  is  clear. 

Urine:  Normal  in  color,  acid,  sp.  gr.  1010,  albumen  a  slight  trace.  The 
diazo-reaction  is  positive.  The  sediment  shows  many  hyaline,  granular,  and 
fatty  casts,  and  compound-granule  and  other  cells. 

May  2.  There  has  been  a  gradual  fall  in  pulse  rate  and  temperature  for 
the  past  four  days  with  slow  improvement  in  the  general  condition  of  the 
patient. 

Heart:  The  sounds  are  of  good  quality,  the  pulse  rather  small  and  soft, 
the  rate  95.  The  nails  and  lips  are  slightly  cyanotic,  and  the  face  and  ears 
are  dusky  in  color.  Blood-pressure,  80/S.-60/D. 

The  patient  complains  only  of  frontal  headache.  He  looks  comfortable 
and  placid  as  always.  The  color  of  the  face  is  distinctly  darker  than  at  the 
time  of  admission.   It  seems  to  be  more  pigmented.    White  count,  16,000. 

May  3.     The  diazo-reaction  is  negative. 

May  Jf.-  Heart:  The  first-sound  is  blurred  and  faint,  and  the  second- 
sounds  are  of  good  quality.  Blood-pressure,  90/S.-50/D. 

The  injection  of  the  conjunctivae  is  practically  gone. 

May  6.  Haemoglobin  (Tallquist),  85-90  per  cent.  Blood-pressure, 
100/S.-60/D. 

The  eruption  is  fading  but  brown  mottling  remains  distinctly  visible. 

Urine:  Normal  in  color,  sp.  gr.  1018,  no  albumen,  the  diazo-reaction  is 
negative.  The  sediment  shows  a  very  large  quantity  of  amorphous  material 
which  is  readily  dissolved  either  by  heat  or  by  acid.  This  sediment  was  be- 
lieved to  be  composed  of  urates. 

White  count,  10,700. 

May  8.  Digitalis  was  ordered  after  the  patient  had  been  in  the  ward  a 
few  days.   It  was  omitted  today  because  the  pulse  rate  fell  to  48. 

Urine:  Normal  in  color,  sp.  gr.  1019,  no  albumen,  many  hyaline  casts. 

May  9.  Heart  action  regular  and  slow.  The  pulmonic  second-sound  is 
accentuated  and  louder  than  the  aortic  second-sound.  The  second-sound  at 
the  apex  is  accentuated.  The  first-sound  is  almost  replaced  by  a  soft 
systolic  murmur  which  is  heard  also  in  the  pulmonic  area  but  is  not  trans- 
mitted to  the  axilla.  Blood-pressure,  105/S.-70/D.  Haemoglobin  (Tall- 
quist), 85  per  cent.  White  count,  7200. 


180 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


May  11.  The  eruption  is  brownish,  with  a  faint  purpHsh  tinge.  It  is  still 
clearly  visible  on  the  body  and  arms. 

Heart:  The  pulmonic  second-sound  is  accentuated,  and  louder  than  the 
aortic  second-sound.   The  second-sound  at  the  apex  is  accentuated.   The 


CUNICAL  CHART 


NAME,.   .StTJCS.    *1 

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Series  Number  1.  Typhus  fever  moderately  se- 
vere; with  mild,  acute  nephritis.  Admitted  to 
hospital  April  23,  1915.  Haemoglobin  estimations, 
red  counts,  white  counts,  and  blood-pressure  are 
recorded  on  the  chart 


first-sound  is  obscured  by  a  systolic  murmur  which  is  not  transmitted  to  the 
axilla.    Blood-pressure,  120/S.-65/D. 

Urine:  Normal  in  color,  neutral,  sp.  gr.  1012,  no  albumen,  rare  hyaline 
casts. 

May  IS.  The  first-sound  is  still  blurred.  Blood-pressure,  125/S.-65/D. 
Haemoglobin  (Tallquist),  65  per  £^nt.  The  eruption  is  pale  pinkish  brown  in 
color. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    181 

May  16.  The  Widal  test  and  agglutination  tests  for  paratyphoid  A  and 
B  were  negative  in  dilutions  of  1  to  25  and  1  to  50. 

The  patient  was  discharged  from  the  hospital  in  excellent  condition. 

Series  Number  9.  Diagnosis:  Typhus  fever,  severe,  with 
nephritis  apparently  becoming  chronic. 

Qlinical  Notes 

Serbian,  age  30,  admitted  to  hospital  on  April  26. 

April  27 .  Present  Illness:  The  patient  says  that  he  has  been  ill  for 
three  days.  The  color  of  the  rash  suggests  that  he  has  been  ill  at  least  a 
week  but  he  may  have  worked  until  three  days  ago. 

Physical  Examination:  The  patient  is  moderately  emaciated,  the  face 
browned  by  the  sun,  the  malar  region  flushed,  the  eyes  hollow,  the  nose 
sharp  and  the  facies  typical  of  typhus.  The  skin  is  dry,  and  the  conjunc- 
tivae are  moderately  injected.  The  tongue  has  a  slight  brown  coat.  The 
nostrils  move  with  respiration  and  the  breathing  is  rapid  and  rather  deep. 
Muscular  twitching  of  the  hands  is  frequent. 

The  eruption  is  scanty  on  trunk  and  legs  and  more  marked  on  the  arms 
and  hips.  It  is  macular  and  punctiform  in  character  and  purple  in  color. 
The  face,  the  backs  of  the  hands  and  those  of  the  feet  show  no  spots. 

April  28.  Heart:  The  action  is  rapid  and  regular.  All  heart  sounds  are 
accentuated.  No  murmurs  are  heard.   The  pulse  is  small  and  weak. 

Lungs:  Many  fine  rales  are  heard  in  the  back,  especially  at  the  bases. 
There  is  no  dulness  and  the  breath  sounds  are  normal. 

The  abdomen  is  concave  and  soft. 

The  abdominal  reflexes  are  lively  and  the  knee-jerks  are  very  sluggish. 
The  neck  is  moderately  stiff  and  Kernig's  sign  is  present  to  a  slight  degree. 
The  muscles  of  the  left  calf  are  sensitive  to  pressure. 

There  is  muttering  delirium  at  times  and  the  patient  is  not  fully  con- 
scious. The  facial  expression  is  that  of  pain.  Gestures  indicate  pain  in  the 
forehead  and  in  the  legs.   The  breathing  is  very  rapid. 

The  Urine  is  of  normal  color,  acid,  sp.  gr.  1015,  and  shows  a  trace  of  al- 
bumen. The  test  for  sugar  is  negative.  Thesediment  shows  many  granular 
and  fatty  casts. 

April  29.  The  body  is  emaciated  and  the  skin  is  dry. 

Heart:  The  sounds  this  morning  are  of  poor  quality,  and  the  pulse  is 
very  weak.  The  systolic  blood-pressure  is  70  mm. 

The  patient  is  conscious  but  mentality  clouded  and  his  movements  are 
tremulous.   He  has  a  frequent,  dry  cough. 

This  morning  about  720  cc.  of  salt  solution  were  given  intravenously. 
The  pulse  rate  dropped  from  140  to  120  while  the  first  500  cc.  were  going 
in  and  the  pulse  improved  much  in  quality  at  the  same  time.  The  injection 


182         CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

was  terminated  later  because  the  pulse  rate  rose  again  to  130,  and  its  qual- 
ity deteriorated.  The  heart  sounds,  however,  remained  excellent.  At  5  p.m. 
the  heart  sounds  were  clear,  the  action  regular,  and  the  rate  134.  The  blood- 
pressure  was  75/S.-60/D.,  and  the  pulse  small  and  weak.  At  6  p.m.  salt 
solution  was  again  administered.  The  pulse  improved  much  at  first  during 
the  injection,  but  after  about  '480  cc  had  been  given  the  patient  coughed 
repeatedly,  the  heart  sounds  which  had  been  abnormally  loud  became 
less  so,  and  the  pulse  deteriorated  again.  The  patient  did  not  look  quite 
so  well  and  seemed  rather  prostrated.  Therefore  the  injection  was  dis- 
continued. 

The  blood  examination  made  one  hour  after  the  first  infusion  of  salt 
solution  showed  a  haemoglobin  (Sahli)  of  125  per  cent,  a  red  count  of 
5,500,000,  a  white  count  of  4000,  and  a  color  index  of  1.13. 

April  30.  This  morning  the  patient  is  weaker  and  semicomatose.  He 
slept  better,  however. 

The  pulse  is  of  very  poor  quality  but  the  heart  sounds  are  fairly  good. 
In  the  afternoon  the  pulse  was  much  stronger  for  a  time,  but  weakened 
again  later.  Salt  solution  was  administered  at  6  p.m.  and  again  at  midnight 
in  small  amounts  with  good  effect. 

May  1 .  The  pulse  is  of  fair  quality  this  morning  and  the  heart  sounds  are 
good. 

■   The  temperature  has  dropped  abruptly  to  normd,l  and  the  pulse  rate  has 
fallen  to  92.     Muscular  twitching  persists. 

May  3.  This  morning  the  patient  is  semicomatose  and  can  only  be 
roused  with  difficulty.  The  pulse  is  very  weak  and  irregular  in  force.  After 
about  720  c.c.  of  salt  solution  had  been  given  intravenously  at  11  a.m.  the 
heart  sounds  became  loud.  The  blood-pressure  was  then  95/S.-70/D. 

May  4.  The  patient  looks  rather  dried  up  this  morning,  but  feels  well 
enough  to  smile. 

The  heart  sounds  are  loud  and  the  pulse  is  of  fair  quality,  the  rate 
being  70. 

The  temperature  has  remained  normal  for  24  hours.  The  respiration  rate 
has  varied  from  20  to  24  during  the  past  three  days. 

May  6.  Patient  passed  only  about  15  c.c.  of  urine  today.  The  bowels 
moved  once  today  and  three  times  freely  yesterday.  The  abdomen  is 
markedly  distended  and  is  tympanitic.  It  shows  slight  general  tenderness. 
There  is  no  dulness  in  the  region  of  the  bladder. 

The  nurse  says  that  the  patient  frequently  takes  from  240  to  300  cc.  of 
liquid  at  a  time.  She  reports  also  that  at  times  the  pulse  is  slciw  and  of 
poor  quality.  Since  the  administration  of  a  little  brandy  one  hour  ago  it  has 
been  excellent.  The  heart  sounds  are  now  of  good  quality  and  the  rate 
moderate.  Digitalis  was  then  prescribed. 
.    The  patient  seems  mentally  dull  and  physically  weak. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    183 

Shortly  after  the  time  mentioned  in  the  last  note  an  enema  was  given 
with  little  effect  on  the  bowels  but  soon  the  patient  voided  about  720  c.c.  of 
urine  and  the  abdominal  distention  nearly  disappeared. 

May  6.  The  patient  is  better  this  morning.  For  the  past  three  days  he 
has  been  asking  for  bread. 

The  pulse  is  of  good  quality  and  the  blood-pressure  is  90/S.-60/D. 

There  is  no  distention.  Patient  is  taking  240  cc.  of  water  every  two 
hours  and  eating  well.  His  face  is  less  emaciated.  Haemoglobin  (Tallquist), 
90  per  cent. 

The  urine  is  acid,  the  sp.  gr.  1025,  and  the  diazo-reaction  is  negative. 
The  sediment  shows  many  hyaline  and  granular  casts,  some  of  them  with 
fat  and  cells  adherent. 

In  the  afternoon  the  left  side  of  the  face  on  which  the  patient  had  been 
lying  was  distinctly  ©edematous . 

May  7.  The  face  and  eyelids  are  slightly  swollen  and  there  is  slight 
oedema  of  left  leg.  The  patient  is  very  drowsy.  Muscular  twitching  and 
cough  have  stopped.  Limitation  of  the  ingestion  of  liquid  was  prescribed. 

Digitalis  was  discontinued  on  account  of  bradycardia. 

May  9.  The  right  side  of  the  face  is  still  slightly  swollen.  The  patient  is 
weak  and  drowsy.  The  bladder  is  distended  nearly  to  the  umbilicus.  The 
patient  was,  therefore,  catheterized.  Haemoglobin  (Tallquist),  90  per  cent. 
Blood-pressure,  100/S.-80/D. 

May  11.  The  patient  now  urinates  normally.  He  is  gaining  strength. 
There  is  no  oedema.  The  ingestion  of  liquids  has  been  limited  to  1000  cc. 
in  24  hours. 

The  aortic  second-sound  is  accentuated,  and  is  louder  than  the  pulmonic 
second-sound.  The  first-sound  is  faint  and  blurred.  Blood-pressure,  105/S.- 
65/D.* 

May  14-  The  patient  is  passing  more  urine  and  his  condition  is  improv- 
ing steadily. 

The  heart  action  is  slow  and  regular,  the  pulmonic  second-sound  is  ac- 
centuated and  louder  than  the  aortic  second-sound.  The  second-sound  at 
the  apex  is  accentuated,  and  the  first-sound  is  nearly  replaced  by  a  systolic 
murmur  which  is  heard  equally  well  in  the  pulmonic  and  mitral  areas,  and  is 
not  transmitted  to  the  axilla.  Blood-pressure,  105/S.-70/D.  Haemoglobin 
(Tallquist),  75  per  cent. 

May  26.  The  Widal  test  and  the  paratyphoid  A  and  B  agglutination 
tests  are  negative  in  dilutions  of  1-25  and  1-50. 

May  30.  The  urine  is  normal  in  color,  the  sp.  gr.  1008,  and  there  is  no 
albumen. 

The  general  condition  of  the  patient  is  good. 

The  fingers  were  almost  completely  paralyzed  for  a  time  but  their 
strength  is  returning.  -• 


184 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


June  2.  The  second-sounds  of  the  heart  are  now  of  good  quahty.  The 
puhnonic  second-sound  is  louder  than  the  aortic  second-sound.  The  first- 
sound  is  blurred  by  a  systolic  murmur  which  is  heard  all  over  the  precordia. 
It  is  loudest  in  the  mitral  area  and  is  not  transmitted  to  the  axilla.  It  dis- 
appears when  the  patient  sits  up.  The  cardiac  dulness  is  slightly  increased 


CUNICAL  CHART 


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Series  Number  9.  Typhus  fevere  severe.  Ne- 
phritis apparently  becoming  chronic.  Admitted 
to  hospital  April  26.  Haemoglobin  estimations, 
red  counts,  white  counts,  and  blood-pressure  are 
recorded  on  the  chart 


to  the  left  and  the  apex  impulse,  when  the  patient  lies  on  the  left  side,  is  felt 
in  the  mid-axillary  line.  Its  force  is  greater  than  normal.  Blood-pressure, 
115/S.-75/D. 

The  lungs  are  negative.  The  skin  and  mucous  membranes  are  abnor- 
mally pale.    Haemoglobin  (Tallquist),  75  per  cent. 

The  patient  is  much  stronger.  He  was  discharged  today,  advice  having 
been  given  about  diet  with  regard  to  signs  of  nephritis. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    185 

Series  Number  10.  Diagnosis:  Typhus  fever  moderately 
severe  with  marked  irregularity  of  the  pulse. 

Clinical  Notes 

Serbian,  age  37,  admitted  to  hospital  on  April  26. 

April  27 .  The  patient  is  said  to  have  been  sick  for  three  days,  but  more 
probably  he  has  been  so  for  a  week. 

Physical  Examination:  The  patient  lies  on  the  side.  He  is  apathetic 
but  mentally  clear  when  aroused.  He  then  becomes  nervous  and  excitable. 
There  is  a  malar  flush,  the  eyes  are  sunken,  the  conjunctivae  are  injected, 
there  is  moderate  emaciation,  and  the  skin  is  dry.  The  pupils  are  large, 
equal,  and  react  to  light.  The  tongue  shows  a  white  coat.  The  throat  is  red. 
There  is  no  glandular  enlargement. 

The  eruption  consists  of  scattered  pink  or  purple  macules  on  the  chest, 
abdomen,  and  back.  The  face,  the  arms  and  the  legs  show  no  eruption. 
The  pink  spots  disappear  on  pressure,  and  the  purple  ones  fade,  but  do  not 
disappear. 

Heart:  The  dulness  is  normal  and  the  action  regular  but  slightly  rapid. 
The  aortic  second-sound  is  muffled  and  the  pulmonic  second-sound  is  faint. 
The  sounds  at  the  apex  are  of  poor  quality  and  the  pulse  is  soft. 

The  Lungs  are  negative. 

The  Abdomen  is  concave,  soft,  and  not  tender.  The  liver  and  spleen  are 
not  palpable. 

Reflexes:  The  abdominal  reflexes  are  absent,  but  the  knee-jerks  are 
present.    The  neck  is  moderately  stiff  and  there  is  a  slight  Kernig's  sign. 

The  calf  muscles  are  not  sensitive  to  pressure.  On  the  left  hip  is  a  purple 
spot  about  6  cm.  in  diameter,  due  probably  to  pressure. 

Treatment:  Ordinary  care  and  cathartics  were  prescribed. 

April  28.  The  face  which  is  much  browned  by  the  sun  has  a  tinge  of 
cyanosis.  The  patient  is  fully  conscious  but  drowsy. 

The  palms  of  the  hands  are  bright  yellow  in  color  and  the  soles  of  the  feet 
are  slightly  yellow. 

The  systolic  blood-pressure  is  80  by  palpation.  By  auscultation  it 
varied  from  90  to  70  but  there  were  heart  beats  which  gave  no  sound  in  the 
artery  which  shows  a  marked  irregularity  of  force.  The  haemoglobin 
(Tallquist)  was  considerably  above  100  per  cent. 

Urine:  Color  high,  acid,  sp.  gr.  1016,  albumen  a  very  slight  trace,  diazo- 
reaction  strongly  positive. 

April  29.  Temperature  falling.  General  condition  about  the  same,  pulse 
weak. 

Haemoglobin  (Sahli),  130  per  cent,  red  count,  5,900,000,  color  index, 
1.10,  white  count,  16,600,  platelets  scarce;  differential  count:  polymor- 


186    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

phonuclears,  72  per  cent,  lymphocytes,  8  per  cent,  large  mononuclears, 
17  per  cent,  transitional  cells,  2  per  cent,  unclassified,  1  per  cent. 

April  30.  Lungs  clear.  Sputum  frothy,  white,  very  viscid.  Pulse  of  poor 
quality  in  the  morning,  better  in  the  afternoon.  Salt  solution  was  admin- 
istered by  rectum. 

May  1 .  The  heart  sounds  are  of  poor  quality.  The  aortic  second-sound 
is  very  indistinct  but  the  second-sound  at  the  apex  is  fairly  loud. 

May  2.   The  patient  is  better  this  morning. 

The  pulse  has  been  irregular  in  force  and  rhythm  ever  since  admission 
and  the  heart  sounds  have  been  of  poor  quality  most  of  the  time.  This 
evening  at  6  p.m.  the  pulse  rate  at  the  wrist  had  risen  from  110  to  120.  The 
heart  rate  at  the  same  time  was  132.  The  face  was  markedly  flushed  and 
there  was  slight  cyanosis  of  ears,  face,  and  finger  nails. 

Heart  dulness  to  the  right  was  slightly  increased. 

The  patient  has  been  getting  salt  solution  by  rectum  every  six  hours  and 
had  720  cc.  yesterday  afternoon  intravenously.  It  was  administered  be- 
cause the  skin  was  very  dry  and  the  body  emaciated  as  if  in  need  of  liquid. 
Last  night  240  cc.  of  salt  solution  were  given  intravenously,  but  the  in- 
fusion was  then  stopped  because  the  heart  sounds  had  become  faint,  and 
because  the  pulse  rate  had  not  diminished.  The  pulse  had  improved,  how- 
ever, in  quality.  Shortly  after  the  infusion  the  patient  had  a  slight  rigor. 
Nothing  of  this  sort  followed  the  first  infusion. 

Blood:  White  count,  14,200,  haemoglobin  (Sahli),  100  per  cent,  red  count, 
5,900,000. 

May  3.   This  morning  the  patient  is  decidedly  better. 

The  aortic  second-sound  is  faint,  but  the  pulmonic  second-sound  is  good. 
The  first  and  second-sounds  at  the  apex  are  excellent.  Blood-pressure, 
85/S.-55/D. 

May  Jf.   The  patient  is  much  brighter. 

The  heart  sounds  are  of  good  quality.  Blood-pressure,  90/S.-60/D. 

There  is  considerable  cough  with  scanty,  viscid  expectoration.  The 
conjunctivae  are  still  injected.     The  tongue  is  clean.  White  count,  9700. 

May  5.    Urine:  Color  normal,  sp.  gr.  1017,  albumen  a  very  slight  trace. 

May  6.  A  few  days  ago  the  patient  complained  of  pain  in  the  tip  of  the 
right  middle  finger.  A  small,  red,  purpuric  spot  was  seen  under  the  skin. 
Following  this  there  was  swelling  of  the  finger  tip.  Yesterday  a  little  pus 
was  evacuated  by  incision. 

The  general  condition  of  the  patient  is  improving  steadily.  The  entire 
face  and  ears  have  been  flushed  and  are  so  still.  The  conjunctivae  are  no 
longer  injected. 

Herpes  appeared  on  the  ear  several  days  ago. 

Blood-pressure,  85/S.-60/D.  Haemoglobin  (Tallquist),  80  per  cent. 
White  count,  6300. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


187 


May  7.   Haemoglobin  (Sahli),  100  per  cent.  Red  count,  4,700,000. 

May  8.   Urine:  Color  high,  acid,  sp.  gr.  1023,  albumen  a  slight  trace. 

May  9.  The  heart  action  is  regular,  and  slow.  The  aortic  second-sound 
is  louder  than  the  pulmonic  second-sound.  The  first-sound  is  blurred  by  a 
faint  systolic  murmur.   Blood-pressure,  95/S.-60/D.   White  count,  5700. 


CUNICAL  CHART 


..Seiies  *  10-. 


_OATE  J p.ril  ,«..B,av .1915." 


MEDICAL  RECORD   BOOK,  VOL. -.  PAGE _  DISEASE .Ty.p.haS {:e.V.e.r....... 


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Series  Number  10.  Typhus  fever,  moderately- 
severe  with  marked  irregularity  of  the  pulse.  Ad- 
mitted to  hospital  April  26.  Haemoglobin,  red 
counts,  white  counts,  and  blood-pressure  are  re- 
corded on  the  chart 


Digitalis  was  omitted  yesterday  morning,  and  the  brandy  which  the 
patient  had  been  having  for  several  days  was  omitted  a  few  days  earlier. 

May  11.   Haemoglobin  (Tallquist),  100  per  cent. 

The  heart  sounds  are  of  good  quality.  The  pulmonic  second-sound  is 
louder  than  the  aortic  second-sound.  A  systolic  murmur  is  heard  over  the 
precordia,  loudest  in  the  mitral  area,  and  not  transmitted  to  the  axilla. 
Blood-pressure,  105/S.-50/D. 


188 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


May  13.    The  face  is  desquamating. 

The  pulse  is  of  good  volume  and  tension.  The  pulmonic  second-sound  is 
louder  than  the  aortic  second-sound  and  both  are  accentuated.  The  first- 
sound  is  blurred  by  a  systolic  murmur.  The  second-sound  at  the  apex  is  ac- 
centuated.    Blood-pressure,  100/S.-55/D. 

Today  the  patient  was  out  of  bed  for  the  first  time. 

May  19.  The  patient's  condition  is  improving  rapidly. 

The  heart  action  is  slow  and  the  sounds  are  of  good  quality  except  the 
first-sound  which  is  faint.  The  pulse  is  small.  Blood-pressure,  100/S.- 
60/D.    Haemoglobin  (Tallquist),  80  per  cent. 

May  30.  The  urine  is  normal  in  color,  sp.  gr.  1018,  no  albumen.  The 
patient  was  discharged  today  in  excellent  condition. 


Series  Number  36.  Diagnosis: 
Mild  typhus.  Bradycardia,  no  drugs 

used. 

Clinical  Notes 

Serbian,  age  26,  admitted  on  April  26. 

April  26.   Said  to  have  been  ill  ten  days. 

April  28.  Urine:  Normal  in  color,  acid, 
sp.  gr.  1017,  no  sugar,  albumen  a  slight 
trace.  The  sediment  shows  a  rare  hyaline 
cast. 

Eruption  Present:  A  complete  examina- 
tion was  not  made  because  the  condition 
of  the  patient  was  satisfactory  and  other 
work  pressing. 

May  8.  The  tongue  is  clean.  The  con- 
junctivae are  injected  on  the  right  side  of 
each  eye  but  not  on  the  left  side.  The  skin 
shows  a  few  spots  of  doubtful  nature.  The 
patient  is  gaining  rapidly  in  strength  and 
his  state  of  nutrition  is  good  but  he  looks 
anaemic.  Haemoglobin  (Tallquist),  80  per 
cent.  Blood-pressure,  120/S.-55/D. 

May  1 1 .  The  patient  was  discharged  as 
cured. 

Series  Number  48.  Diagnosis: 
Typhus  fever;  with  chronic  cervical 
adenitis  and  hysteria  during  conva- 
lescence. 


CUNICAL  CHART 

- DATE   April  T  A  ay  1315 


MEDICAL 

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Series  Number  36.  Typhus  fever, 
mild.  Admitted  to  hospital  April 
26.  Bradycardia.  No  drugs  were 
prescribed 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    189 

Clinical  Notes 

Serbian,  age  30,  admitted  May  12,  by  transfer  from  the  Fourth  Hospital 
to  which  he  went  for  cervical  adenitis  eighteen  days  ago. 

May  12.  Physical  Examination:  On  the  right  side  of  the  neck  is  a  con- 
siderable swelling  due  to  enlarged  glands  embedded  in  swollen,  indurated 
tissue.  In  this  region  there  is  a  discharging  sinus  which  is  not  draining 
freely.  There  is  an  enlarged  gland  beneath  the  jaw.  This  swelling  is 
moderately  sensitive. 

The  tongue  shows  a  white  coat,  the  teeth  are  good,  and  the  pillars  of  the 
fauces  and  the  soft  palate  are  slightly  red.  There  is  a  single  dark  red  papule 
on  the  inside  of  the  right  cheek.  The  patient  is  tremulous  and  breathes 
rapidly.  There  is  an  occasional  hard  cough.  The  sputum  is  scanty  and  con- 
sists of  frothy,  viscid,  blood-streaked  mucus.  The  entire  face  and  ears  are 
hyperaemic,  the  malar  region  not  more  so  than  the  rest. 

The  eruption  is  rose-red  in  color  and  chiefly  macular  in  character.  There 
are  a  few  papules.  They  are  not  petechial.  The  spots  are  numerous  on  the 
chest,  abdomen,  and  back;  fewer  on  the  arms,  legs,  and  feet;  and  absent  on 
the  hands  and  face. 

The  heart  action  is  regular.  The  pulmonic  second-sound  is  slightly  ac- 
centuated and  louder  than  the  aortic  second-sound.  The  first-sound  is  of 
good  quality.  The  pulse  is  of  good  volume  and  fairly  good  tension.  The 
systolic  blood-pressure  is  about  100.  Pressure  from  the  inflated  cuff  of  the 
instrument  caused  the  arm  to  twitch  so  that  an  accurate  reading  was  im- 
possible. 

The  lungs  show  a  few  scattered,  fine  and  coarse,  moist  rales. 

The  abdomen  shows  no  tenderness  or  reflex  spasm  but  there  is  voluntary 
rigidity.  The  spleen  is  not  palpable  but  splenic  dulness  is  slightly  increased. 

The  knee-jerks  are  present.  The  calf  muscles  are  slightly  sensitive  to 
pressure.  Kernig's  test  shows  slight  spasm  of  leg  muscles  and  causes  pain. 
The  neck  is  stiff  and  there  is  pain  when  passive  flexion  is  attempted. 
Haemoglobin  (Tallquist),  90  per  cent. 

May  13.  The  heart  sounds  are  of  good  quality  and  the  pulmonic  second- 
sound  is  louder  than  the  aortic  second-sound.  The  blood-pressure  is  95/S.- 
80/D. 

May  15.  The  heart  sounds  are  all  loud,  but  are  obscured  by  coarse  rales. 
Blood-pressure,  115/S.-60/D.  There  is  considerable  cough  but  the  secre- 
tion is  less  viscid.  The  temperature,  pulse,  and  respiration  are  falling  and 
the  patient  looks  better.  Haemoglobin  (Tallquist),  70  per  cent. 

May  16.  White  count,  16,000. 

May  19.  The  temperature  was  normal  last  night.  The  swelling  on  the 
neck  and  the  local  tenderness  have  diminished  much  under  poulticing. 


190    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

The  heart  sounds  are  loud  and  of  good  quality.  A  faint,  systolic  murmur 
is  heard  in  the  mitral  and  pulmonic  areas.  Blood-pressure,  105/S.-65/D. 
Haemoglobin  (Tallquist),  90  per  cent. 

May  21.   White  count,  3000. 

June  2.  The  patient's  condition  has  improved  rapidly  since  the  tempera- 
ture touched  normal.   The  nutrition  has  been  well  maintained. 

Yesterday  the  patient  walked  outdoors  and  fell  down  but  sustained  no 
apparent  injury.  Today  his  happy  smile  is  gone  and  he  shakes  all  over 
when  approached.  The  knee-jerks  are  much  exaggerated.  He  walks  with  a 
limp,  but  can  walk  without  it.  The  patient  had  a  similar  nervous  disturb- 
ance a  week  ago  following  an  operation  done  in  the  ward  on  a  man  with 
parotitis.  The  disturbance  is  clearly  hysterical.  When  eating  his  meals  the 
patient  appears  perfectly  well.  After  reassurance  and  sitting  outside  on  the 
steps  for  a  little  while,  he  regained  his  normal  condition. 

The  glands  in  the  neck  remain  hard,  but  there  is  much  less  swelling,  and 
the  sinus  is  smaller.   There  is  no  discharge  now. 

Blood-pressure,  115/S.-75/D.  Haemoglobin  (Tallquist),  90  per  cent. 

The  patient  was  discharged  in  good  condition  early  in  June. 

The  adenitis  was  better  but  not  cured. 

Sekies  Number  49.  Diagnosis:  Typhus  fever;  typical  case  of 
moderate  severity. 

Clinical  Notes 

May  13.  Serbian  soldier,  admitted  to  hospital  today,  says  he  has  been 
ill  in  barracks  four  days  and  complains  of  pain  in  forehead,  eyes,  and  legs. 

Physical  Examination:  Well  developed  and  nourished.  The  breathing  is 
rapid  and  accompanied  by  grunting  and  movement  of  the  nostrils,  but  the 
patient  breathes  deeply  and  without  effort.  There  is  a  hard  dry  cough.  An- 
swers to  questions  are  intelligent  and  prompt.  The  pupils  are  equal  and  of 
moderate  size,  the  conjunctivae  are  deeply  injected,  and  the  tongue  shows  a 
heavy,  white  coat.  The  teeth  are  good,  the  pharynx  and  pillars  of  the 
fauces  are  bright  red,  and  the  tonsils  are  enlarged. 

Glands:  The  epitrochlear  glands  are  barely  palpable;  those  in  the 
axillary  and  inguinal  regions  are  not  enlarged,  and  the  posterior  auricular 
glands  are  not  palpable. 

The  whole  face  and  the  upper  part  of  the  neck  are  flushed.  The  suffusion 
is  brightest  on  the  ears  and  in  the  malar  region.  - 

Eruption:  There  is  on  the  face  one  papule  and  several  minute  purple 
spots  which  might  be  old  flea  bites.  There  are  many  macules  on  the  chest, 
the  back  and  the  arms,  and  a  few  on  the  neck,  hands,  legs,  and  upper 
abdomen,  but  none  on  the  lower  part  of  the  abdomen.   The  rash  consists 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


191 


chiefly  of  macules  but  there  are  also  some  papules  resembling  the  rose  spots 
of  typhoid,  and  a  few  punctate  purple  spots,  undoubtedly  flea  bites. 

Heart:    The  action  is  regular  and  rather  rapid,  the  aortic  second- 
sound  is  accentuated  and  louder  than  the  pulmonic  secondrsound.    The 


CUNICAL  CHART 


NAME_.jS.ei-..i.e.s .*.4..S.- 


-BED  NO _ _DATE  .  A  ay .  ,13,..  L9 15. 


MEDICAL  RECORD   BOOK. 


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Series  Number  49.  Typhus  fever  —  a  typical 
case  of  moderate  severity.  Haemoglobin,  white 
count,  and  blood-pressure  are  recorded  on  the 
chart 

first-sound  is  loud  but  blurred.  The  second-sound  at  the  apex  is  accen- 
tuated.  Cardiac  dulness  is  normal.   Blood-pressure,  105/S.-50/D. 

Lungs:  A  few  coarse  rales  are  heard. 

Abdomen  is  soft  and  shows  slight,  general  sensitiveness.  The  spleen 
is  not  palpable  but  splenic  dulness  is  increased.  The  knee-jerks  are  present. 
The  calf  muscles  and  hamstring  muscles  are  sensitive  to  pressure.  Kernig's 
test  causes  pain.  The  neck  is  very  slightly  stiff.  Haemoglobin  (Tallquist), 
85  per  cent. 


192    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

May  15.  The  eruption  is  beginning  to  turn  purple  but  most  of  the  spots 
are  still  pink. 

The  heart  sounds  are  all  of  good  quality,  the  aortic  second-sound  equals 
the  pulmonic  second-sound  and  the  pulse  is  of  the  bounding  type.  Blood- 
pressure,  105/S.-60/D.  Haemoglobin  (Tallquist),  70  per  cent. 

May  16.  White  count,  12,800. 

May  19.  There  has  been  a  rapid  fall  of  temperature  associated  with 
steady  improvement  in  the  condition  of  the  patient.  The  nutrition  is  well 
maintained.  The  eruption  is  turning  brown.  The  leg  muscles  are  no  longer 
sensitive. 

The  second-sounds  are  accentuated,  especially  the  pulmonic  second- 
sound.  The  first-sound  is  of  fair  quality,  the  pulse  is  full  and  soft,  and  the 
blood-pressure  is  110/S.-70/D.   Haemoglobin  (Tallquist),  95  per  cent. 

May  21.  The  patient  is  doing  well.  Blood-pressure,  110/S.-70/D. 
Haemoglobin  (Tallquist),  75  per  cent. 

May  26.  The  convalescence  is  rapid.  Blood-pressure,  110/S.-60/D. 
Haemoglobin  (Tallquist),  90  per  cent.  The  Widal  test  in  dilution  of  1-25  is 
positive  but  in  that  of  1-50  it  is  negative.  Agglutination  tests  for  para- 
typhoid A  and  B  are  negative  at  1-25  and  1-50. 

The  patient  was  discharged  well  about  June  1 . 


Series  Number  57.  Diagnosis:  Typhus  fever;  persistent 
vomiting  in  convalescence,  and  bradycardia.  Four-hourly  tem- 
perature chart,  showing  crisis. 

Clinical  Notes 

May  17.  A  Serbian,  age  20,  admitted  yesterday  afternoon;  and  said  to 
have  been  sick  twelve  or  thirteen  days. 

Physical  Examination:  The  patient  lies  on  his  side  sleeping  comfortably. 
The  breathing  is  rather  rapid  and  deep  but  the  nostrils  do  not  move.  When 
aroused  the  patient  grunts  occasionally  when  breathing. 

The  face  is  brown  and  slightly  flushed  especially  in  the  malar  region.  The 
ears  are  particularly  red. 

The  pupils  are  equal  and  of  normal  size,  the  conjunctivae  moderately  in- 
jected, the  tongue  shows  a  white  coat,  and  the  throat  is  slightly  red. 

The  Eruption  is  macular.  The  spots  are  irregular  in  shape  and  of  various 
sizes.  Their  color  is  purplish  or  bluish  pink.  There  are  a  few  spots  on  the 
neck,  legs,  and  back,  and  many  on  the  shoulders,  upper  chest,  flanks,  and 
abdomen.  The  face,  mucous  membranes,  hands  and  feet  show  no  spots. 

The  Heart  Action  is  regular  and  not  rapid.  The  aortic  second-sound  is 
accentuated,  and  the  pulmonic  second-sound  much  accentuated  and  louder 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    193 

thaD  the  aortic  second-sound.  The  first-sound  is  blurred  by  a  systolic  mur- 
mur which  is  heard  also  in  the  pulmonic  area  but  is  not  transmitted  to  the 
axilla.   The  second -sound  at  the  apex  is  slightly  accentuated.    There  is  a 


MiMe-Sariea— *52 


CUNICAL  CHART 

_WARO_ 


.DATE  .&om  li>,.B15 


Series  Number  57.    Typhus  fever;  four-hourly 
chart  showing  crisis 


marked  pulsation  in  the  neck.  An  excessive  pulsation  is  seen  in  the  second 
and  fourth  interspaces  over  the  heart. 

The  heart  impulse  is  increased  in  force  and  is  best  felt  in  the  fourth 
interspace  in  the  mid-clavicular  Hne.  When  the  patient  lies  on  the  left  side 
an  excessive  impulse  is  felt  in  the  fourth  interspace  in  the  mid-axillary  line. 
No  murmurs  are  heard.  Blood-pressure,  110/S.-85/D. 

The  Lungs  are  negative . 

The  Abdomen  is  flat,  soft,  and  not  sensitive.  Pressure  causes  gurgling, 
especially  in  the  right  ihac  fossa.  The  liver  and  spleen  are  not  palpable 
and  the  splenic  dulness  is  not  increased. 


194    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

The  neck  is  slightly  stiff  and  there  is  a  slight  Kernig's  sign  but  the  test 
does  not  cause  pain.  The  leg  muscles  are  not  sensitive.  The  knee-jerks  are 
present. 

Haemoglobin  (Sahli),  110  per  cent,  red  count,  4,600,000,  white  count, 
7800,  color  index,  approximately  1.30. 

Treatment:  Routine  without  drugs. 


CUNICAL  CHART 


HAME,„  ,S,e.ri  e.s.-.,*  .S.,7.. 


MEDICAL  RECORD  BOOK,  VOL..  _.-    PAGE DISEASE  _1^.p.ku-E,_.f:i 


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Series  Number  57.     Typhus  fever;   persistent 
vomiting  in  convalescence,  bradycardia,  crisis 

May  19.  All  the  second-sounds  are  accentuated  and  especially  the 
puhnonic  second-sound.  The  pulse  is  full,  and  the  blood-pressure,  105/S.- 
65/D. 

The  eruption  is  fading  and  turning  brown.  Haemoglobin  (Tallquist),  95 
percent. 

May  22.  The  patient  is  very  thin.  He  has  vomited  frequently.  (No 
drugs  have  been  used.) 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    195 

The  second-sounds  are  accentuated,  especially  the  pulmonic  second- 
sound.  The  first-sound  is  of  fair  quality.  The  second -sound  at  the  apex  is 
accentuated  and  the  pulse  is  of  fair  quality.  Blood-pressure,  90/S.-65/D. 
Haemoglobin  (Tallquist),  90  per  cent. 

May  23.  The  patient  still  vomits  everything.  Examination  of  the  ab- 
domen is  negative.  Calomel  was  prescribed  yesterday  in  small,  repeated 
doses  and  feeding  was  attempted  in  very  small  quantities  every  hour  but 
the  patient  vomited  even  water.  Nutritive  enemata  and  salt  solution  by 
rectum  were  prescribed. 

May  26.  The  patient  has  not  retained  the  salt  solution  well  and  has  con- 
tinued to  vomit  until  yesterday  afternoon  when  he  was  able  to  keep  down  a 
little  water.  This  morning  he  has  taken  240  c.c.  of  liquid  nourishment  and 
looks  better. 

The  heart  sounds  are  of  good  quality,  the  pulmonic  second-sound  is  ac- 
centuated and  louder  than  the  aortic  second-sound.  The  second -sound  at 
the  apex  is  accentuated  and  the  first-sound  is  of  good  quality.  Blood-pres- 
sure, 105/S.-65/D. 

June  2.   Improvement  is  marked  and  rapid. 

June  11.  There  is  now  no  stiffness  of  neck  or  legs.  The  patient  is  very 
thin,  but  is  fairly  strong.  Blood-pressure,  120/S.-65/D.  He  will  be  dis- 
charged tomorrow. 

Series  Number  59.  Diagnosis:  Typhus  fever;  diarrhoea, 
crisis,  pulmonary  gangrene  in  convalescence. 

Clinical  Notes 

May  19.  Serbian,  age  22.  He  says  that  his  left  eye  became  inflamed 
about  twenty  days  ago  and  that  he  has  had  fever  for  seven  days.  There  has 
been  no  pain  except  in  the  eye. 

Physical  Examination:  The  patient  is  well  developed  and  fairly  well 
nourished.  He  is  fully  conscious  and  mentally  clear.  The  face  is  brownish, 
the  cheeks  moderately  flushed,  and  the  forehead  slightly  so.  The  ears  and 
nose  are  red. 

The  right  pupil  is  very  large,  but  it  reacts  to  light.  The  left  eye  is  in- 
flamed and  sticky.  The  tongue  shows  a  whitish  coat,  the  throat  is  red, 
and  the  tonsils  are  slightly  enlarged. 

The  glands  in  the  axillae  are  enlarged  but  the  posterial  auricular  glands 
are  not  palpable. 

Eruption:  The  face  and  mucous  membranes  are  free  from  spots.  There 
are  a  few  spots  of  doubtful  nature  on  the  neck.  On  the  arms,  the  chest, 
and  the  backs  of  the  hands  there  are  a  few  typical,  pink  spots  which 
disappear  on  pressure.    On  the  abdomen  there  are  a  few  macules  and 


196    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

papules.  Macules  are  seen  faintly  outlined  on  the  legs  and  feet.  The  back 
shows  many  reddish  papules  of  doubtful  nature. 

The  Heart  Action  is  regular  and  rapid.  The  pulmonic  second-sound  is 
accentuated,  and  louder  than  the  aortic  second-sound.  The  second-sound 
at  the  apex  is  accentuated.  The  first-sound  is  blurred  by  a  systolic  murmur 
which  is  loudest  in  the  pulmonic  area  and  is  not  transmitted  to  the  axilla. 
The  pulse  is  of  the  bounding  type.  There  is  excessive  pulsation  in  the  neck. 
The  arteries  are  soft.   Blood-pressure,  125/S.-45/D. 

The  Lungs  are  negative. 

The  Abdomen  is  soft,  full,  and  not  sensitive.  The  spleen  is  palpable  about 
4  cm.  below  the  costal  margin  and  the  splenic  dulness  is  much  increased. 

The  Neck  is  decidedly  stiff  but  an  attempt  at  flexion  does  not  cause  pain. 
The  neck  muscles  are  not  sensitive.  There  is  a  definite  Kernig's  sign  with- 
out sensitiveness  of  calf  or  thigh  muscles.  The  knee-jerks  are  present. 
Haemoglobin  (Tallquist),  95  per  cent. 

Routine  treatment  and  brandy  in  small  quantities  were  prescribed. 

May  21.   White  count,  3900. 

May  22.  The  patient  is  losing  weight  rapidly  although  taking  nourish- 
ment well.  His  color  is  not  good,  the  pulse  is  of  poor  quality.  Blood-pres- 
sure, 105/S.-50/D.  Haemoglobin  (Tallquist),  75  per  cent. 

Digitalis  and  extra  diet  were  prescribed. 

May  23.  The  patient  is  taking  nourishment  well  but  continues  to  lose 
weight  and  strength.  His  condition  is  critical.  The  eruption  has  become 
profuse  all  over  the  body  and  limbs,  and  is  turning  purple. 

Nutrient  enema  of  syrup,  60  cc.  in  480  cc.  of  water  were  administered 
every  six  hours. 

May  26.  Urine:  Color  high,  neutral,  sp.  gr.  1012,  no  albumen,  diazo- 
reaction  strongly  positive. 

May  28.  The  patient  began  to  have  diarrhoea  yesterday  and  it  became 
profuse  to  day.  The  stools  are  of  the  pea  soup  variety,  and  not  offensive. 
There  is  incontinence  of  the  bowels. 

The  mouth  has  been  very  foul.  The  nurse  says  it  has  required  cleaning 
hourly. 

The  patient  is  mildly  delirious,  picks  at  the  bedclothes,  and  is  extremely 
weak. 

The  pulse  has  remained  full  and  of  good  quality.  Blood-pressure  at  6  p.m. 
95/S.-45/D.  The  aortic  second-sound  is  faint  and  the  pulmonic  second- 
sound  of  fair  quality.  The  first-sound  is  faint  and  second-sound  at  the 
apex  is  accentuated. 

May  29.  The  patient's  condition  was  so  bad  yesterday  evening  that  he 
was  not  expected  to  live  through  the  night.  He  was  extremely  weak  and 
seemed  too  tired  to  breathe,  but  the  pulse  continued  pretty  good.  Salt 
solution,  480  cc,  was  given  intravenously  in  the  evening  with  benefit. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    197 

This  morning  after  the  crisis,  the  patient's  condition  is  still  bad.  Although 
the  pulse  was  satisfactory,  salt  solution  was  given  again  intravenously  to 
make  up  for  fluid  lost  by  diarrhoea.  Fifteen  minutes  after  the  infusion  the 
pulse  became  very  weak  and  irregular,  and  the  patient  seemed  about  to  die. 


CUNICAL  CHART 


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Seeies  Number  59.  Tjrphus  fever;  severe  diar- 
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The  pulse  afterwards  improved  slowly,  and  in  the  evening  it  was  decidedly 
better. 

June  2.  Opium  was  used  for  a  few  days  to  check  the  diarrhoea,  but  the 
stools  then  became  foul.  The  opium  was  consequently  discontinued,  the 
quantity  of  food  was  reduced,  and  castor  oil  administered.  Today  the 
patient  seems  out  of  danger.  He  has  a  small  black  patch  over  the  sacrum 
which  appeared  about  the  time  of  the  crisis  but  which,  probably,  will  not 
slough. 


198    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

June  11.  Since  June  fourth  there  >as  been  gradually  increasing  irregular 
fever  with  slight  constitutional  symptoms. 

About  the  time  of  the  crisis  and  for  several  days  the  patient  was  ex- 
tremely sensitive  all  over.  Any  motion  or  attempt  at  motion  caused  great 

pain. 

Examination  today  with  the  patient  lying  on  the  left  side  shows  a  few 
rales  at  the  left  base  behind  and  slight  sensitiveness  in  the  right  flank  with- 
out spasm.  The  patient's  appearance  suggests  tuberculosis.  He  has  been 
raising  much  sputum  which  is  frothy  and  tenacious.. 

June  12.   Urine:  High  colored,  sp.  gr.  1013,  no  albumen  or  bile. 

June  24.  The  sputum  became  foul  about  a  week  ago  and  a  small  area  of 
dulness  with  a  few  rales  was  found  at  the  right  base  in  the  axilla.  The  rales  at 
the  left  base  meanwhile  disappeared. 

Moderate  elevation  of  temperature  persists.  The  sputum  continues  to  be 
raised  in  considerable  quantity  and  is  foul  at  times.  More  often  it  is  frothy 
and  inoffensive.  Microscopic  examination  shows  no  tubercle  bacilli.  There 
are  great  numbers  of  Gram-negative  influenza-Uke  bacilli,  besides  bacteria 
of  many  kinds,  and  a  few  pneumococci  and  spirochaetae. 

The  patient  remained  in  the  hospital  on  account  of  these  pukaonary 
symptoms  and  had  periods  of  improvement  followed  by  exacerbations.  He 
was  last  seen  about  the  end  of  August  still  in  the  hospital. 


Series  Number  60.  Diagnosis:  Typhus  fever.  Mild  paro- 
titis in  convalescence. 

Clinical  Notes 

May  19.  Physical  Examination:  The  patient  is  too  dull  and  confused  to 
reply  to  questions  rationally.  The  face  is  much  tanned  and  the  cheeks  are 
slightly  flushed.  The  pupils  are  equal  and  of  normal  size.  The  tongue 
shows  a  brownish  coat.  The  throat  is  negative  and  the  mucous  membranes 
are  free  from  spots. 

The  Eruption  is  scanty  on  the  neck  and  hands  and  indefinite  on  the  legs. 
The  chest,  flanks,  abdomen,  back,  and  arms  are  profusely  covered  with 
small  purplish-brown  spots.  There  are  a  few  minute  purple  spots  on  the 
forearms  and  elsewhere.  Evidently  they  are  flea  bites. 

Heart:  The  puhnonic  second-sound  is  accentuated  and  occasionally 
redupHcated.  It  is  louder  than  the  aortic  second-sound.  The  second-sound 
at  the  apex  is  accentuated.  The  first-sound  is  faint,  and  blurred  by  a  soft, 
systoHc  murmur  which  is  best  heard  in  the  puhnonic  area.  Blood-pressure, 
90/S.-50/D. 

The  Lungs  are  negative. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY        199 

The  Abdomen  is  flat,  soft,  and  not  tender.  The  liver  and  spleen  are  not 
palpable  and  the  splenic  dulness  is  not  increased. 

The  neck  is  very  slightly  stiff,  but  the  neck  muscles  are  not  sensitive. 
Kernig's  sign  is  present,  slight  in  degree.  The  test  causes  no  pain.  The 
muscles  are  not  sensitive  to  pressure. 

Treatment  consisted  of  routine  measures  without  drugs. 

May  22.  The  right  cheek  began  to  swell  yesterday  in  the  region  of  the 
parotid  gland.  The  temperature  rose  a  little.  Cold  compresses  were  applied 
locally. 

June  2.  The  tenderness  and  swelling  of  the  parotid  have  never  been 
great.  The  swelling  diminished  markedly  two  days  ago  after  poulticing. 
Now  there  is  no  tenderness  and  no  pain.  The  swelling  which  remains  is 
slight,  and  very  hard.  There  is  slight,  irregular  fever,  but  the  patient  looks 
and  feels  well. 

June  10.  Discharged  well  except  for  slight,  hard  swelling  of  the  parotid 
gland. 

Series  Number  61.  Diagnosis:  Typhus  fever;  severe  case, 
eruption  peculiar,  delirium  violent. 

Clinical  Notes 

May  20.   Patient  was  admitted  yesterday. 

Physical  Examination:  The  patient  is  drowsy  but  rational.  The  entire 
face  is  flushed,  especially  the  cheeks  and  ears.  The  pupils  are  small,  equal, 
and  react  to  light.  The  conjunctivae  are  red.  The  tongue  shows  a  brownish 
coat,  the  throat  is  slightly  red,  and  the  mucous  membranes  are  free  from 
spots. 

Eruption:  The  lower  part  of  the  neck,  the  chest,  and  the  arms  show 
many  rose-pink  macules  which  disappear  entirely  on  pressure  and  which 
are  not  elevated.  There  are  a  few  macules  on  the  abdomen,  legs,  and  feet. 
The  flanks  show  a  few  papules  which  are  redder  in  color  than  the  macules- 
and  which  do  not  disappear  entirely  on  pressure.  The  face  and  hands  are 
free  from  spots. 

Extensive  pink  mottling  is  seen  on  the  back  and  there  are  blotches  of 
irregular  outline  and  considerable  size  scattered  over  the  trunk.  They  re- 
semble pityriasis  rosea. 

Heart:  Dulness  is  normal  in  extent.  The  sounds  are  of  good  quality 
except  the  aortic  second-sound  which  is  rather  faint.  The  pulse  is  of  good 
volume  and  tension. 

The  Lungs  are  negative. 

The  Abdomen  is  very  soft  and  tympanitic.  It  shows  considerable  general 
tenderness  without  spasm.  The  spleen  is  palpable  on  deep  breathing  and^ 
the  splenic  dulness  is  increased. 


200    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

The  neck  muscles  are  very  sensitive  to  pressure  and  the  neck  is  stiff. 
The  hamstring  and  calf  muscles  are  very  sensitive,  and  the  thigh  muscle  in 
front  is  less  so,  and  the  biceps  is  still  less  sensitive.  Kernig's  sign  is  positive 
but  slight  in  degree.   The  test  causes  pain.   Routine  treatment  prescribed. 

May  SI.  White  count,  8C00. 

May  26.  The  patient  has  been  delirious  since  admission.  At  first  he 
would  get  up  and  try  to  leave  the  ward.  The  night  before  last  the  deUrium 
became  so  violent  that  the  patient  had  to  be  tied  in  bed.  This  morning  he 
was  quiet  but  mentally  confused. 

The  face  has  become  several  shades  darker  in  color.  The  conjunctivae 
are  still  deeply  injected.  The  patient  lies  on  his  back  and  dozes  with  eyes 
half  open. 

Heart:  The  pulmonic  second -sound  is  accentuated  and  louder  than 
the  aortic  second-sound.  The  first-sound  is  of  good  quality.  The  pulse  is  of 
good  volume.  Blood-pressure,  95/S.-65/D.  Haemoglobin  (Tallquist),  75 
per  cent. 

May  27.   The  pupils  remain  contracted. 

June  12.  This  patient  has  been  very  ill  and  has  gained  strength  slowly. 
He  has  been  drowsy  and  lethargic  but  now  looks  decidedly  better.  For 
several  days  his  bed  was  put  out  of  doors  but  for  the  past  three  days  he  has 
been  able  to  walk  out.  Today  he  returned  complaining  of  headache.  The 
weather  has  been  very  hot. 

Three  days  ago  white  spots,  like  thrush,  appeared  in  the  throat.  They 
are  clearing  up  now. 

Examination  of  the  heart  shows  the  first-sound  short  but  louder  than 
the  second-sound  and  the  pulmonic  second-sound  louder  than  the  aortic 
second-sound  which  is  faint.  Blood-pressure,  125/S.-60/D. 

The  skin  and  mucous  membranes  are  pale.  Haemoglobin  (Tallquist),  90 
per  cent. 

An  iron  tonic  and  small  doses  of  digitalis  were  prescribed. 

June  18.  The  patient  is  rather  pale  and  lethargic.  His  condition  is 
otherwise  satisfactory.  He  will  be  discharged  tomorrow. 


Sekies  Number  83.  Diagnosis:  Typhus  fever.  Bradycardia; 
heartblock  (?).     Digitalis  used. 

Clinical  Notes 

May  25.  The  patient  says  he  was  ill  for  a  week  before  admission. 
Physical  Examination:  The  patient  is  mentally  clear  and  alert.    The 
tongue  shows  a  brownish  coat. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


201 


The  Heart  Action  is  regular,  the  sounds  at  the  base  are  of  good  quaHty 
but  at  the  apex  they  are  faint.  The  pulmonic  second-sound  is  accentuated 
and  louder  than  the  aortic  second -sound .  The  pulse  is  small  and  rapid. 


CUNICAL  CHART 


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Series  Number  83.    Typhus  fever.   Bradycardia, 
heart-block  (?).    Digitahs  used 

T^e  Lung's  are  negative. 

The  Abdomen  is  negative.  The  spleen  is  not  palpable  but  splenic  dulness 
is  increased. 

The  neck  is  not  stiff  and  Kernig's  sign  is  absent.  The  knee-jerks  are 
sluggish.   Digitalis  was  prescribed. 

May  26.  (Morning.)  The  soft  palate  and  the  pharynx  are  red.  On  the 
palate  is  a  single  minute  red  spot.  The  entire  face  is  flushed  and  especially 
the  cheeks  and  ears.  The  conjunctivae  are  much  injected.  The  pupils  are 
small. 

There  are  a  few  spots  on  the  neck.  The  chest,  the  back,  the  abdomen, 
and  the  backs  of  the  feet  and  hands  are  profusely  sprinkled  with  spots. 


202    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

The  neck  is  not  stiff  or  sensitive.  There  is  a  shght  bilateral  Kernig's  sign 
more  definite  on  the  right.  Performance  of  the  test  causes  pain  in  the  ham- 
string muscles.   They  are  slightly  sensitive  to  pressure. 

The  patient  is  rational  but  rather  dull. 

The  pulse  has  been  of  poor  quality  since  admission.  Blood-pressure, 
75/S.-55/D. 

The  condition  of  the  patient  is  otherwise  excellent.  Haemoglobin  (Tall- 
quist),  90  per  cent.     The  urine  is  high  colored. 

Increased  ingestion  of  water  was  prescribed  and  a  small  dose  of  strych- 
nin every  four  hours. 

May  26.  (Afternoon.)  Every  third  or  fourth  heart  beat  is  skipped.  The 
sounds  are  loud.  The  pulse  is  now  of  good  volume  and  tension.  Digitalis 
omitted.   The  doses  taken  since  admission  have  not  been  large. 

May  27.  The  cardiac  irregularity  is  less  pronounced  but  the  pulse  rate 
continues  to  fall. 

June  12.  Haemoglobin  (Tallquist),  90  per  cent. 

The  heart  action  is  rapid  again  and  regular.  The  pulmonic  second-sound 
is  louder  than  the  aortic  second-sound.  The  first-sound  is  louder  than  the 
second-sound  at  the  apex.  In  the  aortic  region  a  short,  scratchy  systolic 
murmur  resembling  a  pericardial  friction  rub  is  heard.  Blood-pressure, 
115/S.-75/D.  Digitalis  was  prescribed  again. 

June  13.  Because  the  pulse  rate  fell  markedly  and  irregularity  recurred 
the  digitalis  was  omitted  this  morning.  In  the  afternoon  the  pulse  was 
again  more  rapid  and  there  was  no  arrhythmia.  The  patient  had  been 
walking  about  the  ward  a  little.  Blood-pressure,  120/S.-80/D. 

June  20.  Discharged  in  good  condition. 

Series  Number  92.  Diagnosis:  Typhus  fever  in  an  old  man; 
mild;  premature  systoles. 

Clinical  Notes 

June  11.  Nationality  Turkish,  age  60. 

Present  Illness:  Admitted  yesterday  having  been  "sick  eight  days."  The 
patient  was  incontinent  last  night  and  is  so  today.  He  was  stuporous 
yesterday  but  is  brighter  today.  He  is  taking  nourishment  fairly  well  in 
small  quantities.  There  is  no  cough  or  expectoration. 

Physical  Examination:  The  patient  is  very  drowsy,  but  when  aroused 
replies  intelhgently.  He  lies  most  of  the  time  with  the  eyes  half  closed  and 
the  mouth  open,  grunts  occasionally  but  breathes  easily  and  does  not 
cough.  The  skin  is  rough  and  dry.  The  body  is  well  developed  but  ema- 
ciated and  dried  up. 

The  face  is  very  brown  but  markedly  flushed.  The  hyperaemia  extends 
over  the  forehead  and  neck  and  down  on  to  the  upper  part  of  the  sternum. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


203 


The  conjunctivae  are  moderately  injected.  The  pupils  are  equal,  of  moder- 
ate size,  and  react  to  light.  The  tongue  shows  a  heavy  brownish  coat.  It  is 
dry  and  fissured.  The  throat  is  red  and  sticky  mucus  adheres  to  it. 

Eruption:   The  chest,   arms,  abdomen,  and  back  show  many  spots 
midway  between  the  pink  and  purple  stages.  The  spots  are  macular,  and 


CUNICAL  CHART 


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Series  Number  92.   Typhus  fever  in  an  old  man; 
mild;  premature  systoles 


they  nearly  disappear  on  pressure.  The  legs,  backs  of  the  forearms,  hands 
and  feet  and  face  are  free  from  spots. 

The  heart's  action  is  regular.  The  aortic  second-sound  is  slightly  ac- 
centuated and  the  pulmonic  second-sound  is  faint.  The  second-sound  at  the 
apex  is  accentuated  and  the  first-sound  has  a  valvular  quality.  Blood-pres- 
sure, 85 /S. -65 /D. 

The  Lungs  are  negative. 

The  Abdomen  is  soft  and  is  not  sensitive.  Peristalsis  is  visible.  The  liver 
and  spleen  are  not  palpable  and  splenic  dulness  is  not  increased. 


204    CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 

The  neck  cannot  be  bent  forward  at  all,  but  rotation  is  free.  There  is  no 
sensitiveness  of  the  neck  muscles.  The  Kernig's  sign  is  present  and  this 
test  causes  pain.  The  knee-jerks  are  present,  but  very  sluggish.  The  ab- 
dominal and  plantar  reflexes  are  present  and  lively.  Haemoglobin  (Tall- 
quist),  85  per  cent. 

Prescribed  brandy,  15.0  cc.  and  digitalis,  0.6  gm.  every  four  hours. 

June  15.  The  heart  sounds  are  of  fair  quality.  Single  or  double  prema- 
ture systoles  are  heard  occasionally.  The  pulse  is  of  good  volume  and  fair 
tension.  Blood-pressure,  90/S.-55/D. 

The  eruption  is  fading.  Only  a  few  pale,  brown  spots  remain. 

The  patient  sleeps  a  great  deal.  He  has  always  taken  nourishment  well 
and  seems  to  be  improving.  He  has  given  no  cause  for  alarm.  Constipation 
is  very  obstinate. 

June  18.  The  aortic  second-sound  is  faint,  the  pulmonic  second-sound  is 
of  fair  quality,  and  the  first-sound  is  short.  The  second-sound  at  the  apex  is 
good.    Blood-pressure,  90/S.-55/D. 

June  25.   Discharged  in  good  condition. 

Series  Number  93.  Diagnosis:  Typhus  fever;  broncho- 
pneumonia; dry  pleurisy. 

Clinical  Notes 

Present  Illness:  Serbian,  age  40,  admitted  to  the  wards  of  a  colleague 
June  5  and  transferred  to  the  writer  on  June  8.  The  patient  is  said  to  have 
been  ill  eight  days  before  admission  and  to  have  had  an  eruption  which 
first  appeared  nine  days  ago. 

June  11.  Physical  Examination:  The  patient  is  drowsy,  but  easily 
aroused  and  is  then  apprehensive  because  every  movement  which  involves 
the  shoulder  causes  pain.  He  appears  to  be  rational.  The  respiration  is 
rapid  and  shallow  and  the  nostrils  move. 

The  face  is  very  brown  and  there  is  a  slight  malar  flush.  The  pupils  are 
equal,  of  medium  size,  and  react  to  light.  The  tongue  shows  a  heavy  brown- 
ish coat.  The  throat  is  reddish  and  there  is  sticky  mucus  adherent.  The 
skin  is  dry  and  rough. 

The  eruption  is  profuse,  purple,  blotchy,  and  is  beginning  to  turn  brown. 
It  is  abundant  on  the  chest,  abdomen,  and  back,  and  less  so  on  the  arms  and 
thighs.  The  forearms,  lower  legs,  feet,  and  hands  are  free  from  it  or  nearly 
so.  :: 

-  The  heart  action  is  very  rapid  but  regular.  The  aortic  second-sound  is 
louder  than  the  pulmonic  second-sound.  The  second-sound  at  the  apex  is 
accentuated.  The  first-sound  is  short  and  has  a  valvular  quality.  The 
pulse  is  small  and  of  low  tension.  Blood-pressure,  80/S.-60/D. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    205 

The  Lungs  are  negative. 

The  Abdomen  is  soft  and  seems  to  be  acutely  sensitive  all  over.  Pressure 
anywhere  on  the  abdomen  causes  the  patient's  face  to  show  signs  of  pain. 
The  spleen  is  not  palpable  and  the  splenic  dulness  is  not  increased. 
-  The  neck  is  very  stiff  and  the  neck  muscles  are  sensitive.  The  head  ro- 
tates freely  but  cannot  be  bent  forward.  The  Kernig's  sign  is  well  marked. 
The  muscles  of  the  thighs  and  calves  appear  to  be  very  sensitive  to  pres- 
sure. 

For  three  days  the  patient  has  been  receiving  0.6  gm.^of  digitalis  and 
15.0  cc  of  brandy  every  four  hours.  The  night  before  last  salt  solution  by 
rectum  every  six  hours  was  prescribed.  At  first  it  was  all  retained,  but  how 
some  of  it  is  being  lost.  The  bowels  became  incontinent  yesterday. 

The  patient  coughs  much  but  expels  the  secretion  with  great  difficulty 
because  he  is  very  weak  and  the  sputum  is  extremely  viscid.  It  frequently 
causes  a  rattle  in  the  throat. 

The  nourishment  was  well  taken  until  last  night. 

The  pulse  is  more  rapid  and  becomes  bad  whenever  the  patient  is  dis- 
turbed. The  blood-pressure  at  11.30  a.m.  was  75/S.-65/D.  The  aortic 
second-sound  was  of  fair  quality.  The  pulmonic  second-sound  and  the 
first-sound  were  faint.  At  5  p.m.  the  blood-pressure  was  80/S.-65/D.,  and 
the  heart  sounds  as  before.  The  pulse  was  very  weak.  The  area  of  heart 
dulness  was  less  than  normal.    (Front  of  chest  hyperresohant.) 

The  Lungs  were  practically  clear  and  the  breathing  easy  but  rapid.  At 
5.30,  about  480  cc  of  salt  solution  were  administered  intravenously. 
During  the  injection  the  pulse  improved  in  quality,  and  the  heart  sounds 
became  stronger;  the  blood-pressure  after  the  injection  was  83/S.-60/D. 
Half  an  hour  before  the  injection  the  pulse  rate  was  140.  Immediately  after 
the  injection  it  was  varied  between  132  and  136.  About  15  or  20  minutes 
after  the  infusion  the  patient  had  a  prolonged  and  severe  rigor  during  which 
his  color  became  dusky  and  the  pulse  scarcely  perceptible.  The  rigor  lasted 
about  15  minutes  and  the  patient's  condition  afterward  Wap  much  the  same 
as  before  the  infusion.  Haemoglobin  (Tallquist),  100  per  cent. 

June  13.   The  temperature  is  falhng  and  the  condition  has  improved. 

June  16.  Yesterday  afternoon  the  patient's  condition  again  became 
critical.  He  was  given  tea  last  night.  He  rallied  again  this  morning  and 
now  seems  decidedly  better.  The  eruption  is  fading.  Blood-pressure  at 
noon,  90/S.-75/D. 

For  the  past  three  days  he  has  been  taking  nourishment  poorly. 

June  17.  There  has  been  severe  diarrhoea  for  several  days.  Opium  and 
an  astringent  mixture  were  given  to  check  it. 

Last  night  the  circulatory  condition  was  unsatisfactory.  Salt  solution, 
about  360  cc,  were  given  intravenously.  There  was  no  rigor.  The  pulse 
is  of  fair  quality  this  morning. 


206 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY 


There  is  a  good  deal  of  cough  and  a  considerable  quantity  of  thick, 
whitish  expectoration.  Nourishment  is  taken  better  this  morning. 

Urine:  Normal  color,  sp.  gr.  1016,  no  albumen,  no  bile. 

The  pulse  in  the  afternoon  became  poor  in  quality.  The  rate  was  104. 
Salt  solution  was  prepared  in  the  most  careful  way,  the  temperature  care- 


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Series  Number  93.   Typhus  fever,  severe;  bron- 
chopneumonia, dry  pleurisy 


fully  regulated,  and  about  480  cc.  were  given  intravenously.  The  patient 
had  a  severe  rigor  after  it.  He  was  then  given  a  small  dose  of  morphin 
subcutaneously  and  slept  well. 

June  18.  Blood-pressure  this  morning  100/S.-75/D. 

June  24.  Since  the  19th  there  has  been  a  gradual  fall  of  temperature  and 
slow  but  steady  improvement  in  the  patient's  condition. 

About  June  20  a  friction-rub  was  heard  at  the  right  base.  Yesterday  the 
lungs  were  negative  except  for  a  few  rales  at  the  bases. 


CASES  OF  TYPHUS  FEVER  WITH  RECOVERY    207 

The  patient  occasionally  expectorates  thick  lumps  of  whitish  mucus 
with  great  difficulty  on  account  of  weakness.  He  succeeds  only  with  help 
and  encouragement  from  the  nurse. 

The  sputum  looks  as  if  it  came  from  the  nasopharynx,  but  the  nurse  feels 
sure  that  it  is  raised  from  the  chest.  Microscopical  examination  of  the 
sputum  shows  no  tubercle  bacilli,  but  many  pneumococci  and  various  other 
bacteria  are  present.  There  are  a  few  spirochaetae  and  influenza-like  bacilli 
and  a  very  few  pus  cells.    The  sputum  has  had  a  foul  odor  occasionally. 

July.  When  last  seen  the  patient  was  convalescent  and  had  no  cough. 
But  for  the  remarkably  assiduous  care  of  the  nurse  the  pulmonary  complica- 
tions would  almost  certainly  have  proved  fatal. 

The  diagnosis  of  bronchopneumonia  in  this  case  was  based  on  severe 
pulmonary  symptoms  combined  with  a  secondary  rise  of  temperature. 


TYPHUS  FEVER,  FATAL  CASES.    AUTOPSY 
Autopsy  Number  4.     Patient  of  Dr. . 


Diagnosis:  Typhus  fever,  pulmonary  oedema,  bronchitis. 
Died,  probably,  during  the  stage  of  nervous  depression. 
Apparent    Cause    of   Death:    Acute   myocardial  weakness, 
chronic  nephritis,  and  (?)  early  pneumonia. 

Clinical  Notes 
Rapid  breathing,  etc.,  before  death  suggested  pneumonia. 

Autopsy  Findings 

Postmortem  performed  24  hours  after  death.  Body  emaciated  and 
livid. 

Heart:  Not  dilated,  muscle  pale,  rather  flabby.  Mitral  orifice  slightly 
large.  Valves  natural.  An  ante-mortem  (?)  thrombus  was  found  in  the  left 
ventricle. 

Lungs:  Many  pleural  adhesions,  bilaterally  distributed,  some  old,  others 
more  recent.  On  the  pleural  surface  at  the  right  apex  a  fresh  haemorrhage 
was  found.  The  right  upper  lobe  was  oedematous  and  congested.  The  left 
lung  was  deeply  congested  throughout.  Even  the  apex  was  oedematous. 

In  the  bronchioles  of  the  left  lower  lobe  purulent  exudate  was  found. 

Liver:  Pale  and  slightly  fatty. 

Spleen:  Large,  dark  red,  confluent. 

Kidneys:  Slightly  diminished  in  size,  capsules  firmly  adherent.  Surface 
of  section  pale,  cortex  and  medulla  not  markedly  abnormal  but  slightly 
congested. 

Specimens:  Left  kidney,  right  ventricle,  lower  lobe  of  left  lung,  spleen, 
and  liver. 

Autopsy  Number  5.     (A  I.)     Patient  of  Dr.  Smith. 
Diagnosis:  Typhus  fever. 
Died  during  the  postfebrile  stage. 

Apparent  Cause  of  Death:  Gradual  exhaustion  and  cardiac 
weakness. 

Clinical  Notes 

The  day  before  he  died  the  patient  was  semicomatose,  delirious,  and 
prostrated.  The  pulse  was  of  the  Corrigan  type  and  a  diastolic  murmur  was 

208 


TYPHUS  FEVER  —  FATAL  CASES  —  AUTOPSY  209  , 

heard  near  the  fourth  left  costal  cartilage.  About  360  cc  of  salt  solution  was 
given  under  the  pectoral  muscle  in  the  afternoon.  The  next  morning  the 
patient's  condition  was  worse,  but  the  force  and  volume  of  the  pulse  was 
good.  Half  an  hour  later  he  died.  The  patient  had  passed  through  the 
febrile  period  of  typhus  before  death. 

Autopsy  Findings 

Body  of  young  man,  extremely  emaciated. 

Heart:  Slightly  dilated;  muscle  flabby.  Slight  old  thickening  of  mitral 
valve.    Aortic  valves  normal. 

Passive  Congestion  of  all  orgBiTiS. 

Stomach:  Extremely  distended  with  air. 

Specimens:  Heart  muscle,  liver,  spleen,  kidney. 

This  case  called  to  mind  one  in  which  Dr.  Smith  saw  tetany  for  several 
days,  followed  by  recovery.  Was  the  tetany  due  to  gastric  dilatation? 

Autopsy  Number  6.     (A  II.)     Patient  of  Dr.  Smith. 
Diagnosis:  Typhus  fever. 

Died  during  the  stage  of  nervous  depression  or  later. 
Apparent  Cause  of  Death:  Gradual  exhaustion.    Old  mitral 

stenosis  found. 

Clinical  Notes 

Age  45.    Died  late  in  disease. 

Autopsy  Findings 

The  body  is  emaciated. 

Heart:  Left  ventricle  considerably  hypertrophied  and  firmly  contracted. 
Right  ventricle  dilated,  muscle  firm.  Mitral  orifice  stenosed,  cresentic  in 
shape,  admits  one  finger  with  difficulty.   Other  valves  natural. 

Lungs:  Many  dense  fibrous  adhesions  of  the  pleura.  A  nodule  at  the  left 
apex,  probably  tuberculous;  old  scars  at  right  apex. 

Spleen:  Large  and  soft,  surface  of  section  pale. 

Liver:  Large,  deeply  congested,  slight  fatty  degeneration. 

Kidneys:  Appear  normal. 

Specimens:  Left  ventricle,  spleen,  liver,  kidney. 

Autopsy  Number  7.     Patient  of  Dr.  Holmes. 
Diagnosis:  Typhus  fever,  lobar  pneumonia. 
Death  during  the  stage  of  nervous  depression  or  later. 
Apparent  Cause  of  Death:  Lobar  pneumonia  as  a  complica- 
tion. 


210     TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

Clinical  Notes 

On  admission,  April  26,  patient  was  said  to  have  been  sick  eight  days, 
but  the  presence  of  a  scanty,  old  rash  made  it  probable  that  he  had  been  ill 
longer  than  the  time  stated. 

The  temperature  dropped  to  101°  on  the  second  day  after  admission  and 
continued  at  about  that  level,  with  the  pulse  at  from  90  to  100,  and  the 
respiration  at  from  24  to  26  until  the  patient  died  on  May  5. 

Autopsy  Findings 

Postmortem  performed  four  hours  after  death. 

Body  covered  with  small  petechial  spots. 

Heart:  Muscle  firm  and  dark  in  color.  No  dilatation.  Valves  not  re- 
markable. 

The  Aorta  showed  slight  atheroma  of  the  first  part  of  the  arch. 

Lungs:  All  except  the  apex  of  the  upper  lobe  of  the  left  lung  was  con- 
soHdated  as  was  also  the  right  lower  lobe.  The  process  was  evidently  recent. 

Liver:  Deeply  congested. 

Spleen:  Large,  soft,  dark  red. 

Kidneys:  Marked  passive  congestion. 

Specimens:  Left  ventricle,  kidney,  heart.     (No.  A.) 

Autopsy  Number  8.    Patient  of  Dr. . 

Diagnosis:  Typhus  fever. 
Died  during  the  postfebrile  stage. 

Apparent  Cause  of  Death:  Gradual  exhaustion  with  circula- 
tory weakness,  probably  vascular  in  origin. 

Clinical  Notes 

Toward  the  end  of  defervescence  the  patient  developed  signs  of  circula- 
tory weakness  which  increased  in  spite  of  medication  until  he  died  a  week 
later.  Salt  solution  was  not  administered. 

Autopsy  Findings 

Postmortem  performed  sixteen  hours  after  death. 

Extreme  emaciation,  muscles  very  dry. 

Heart:  Right  ventricle  not  dilated.  Left  ventricle  firmly  contracted. 
Valves  appear  normal. 

Lungs:  Pale,  anterior  borders  emphysematous,  posterior  margins  con- 
gested. There  is  a  recent  infarct,  deep  red  in  color,  2.5  to  4  cm.  in  diameter 
at  the  anterior  margin  of  the  right  lower  lobe. 

Liver:  Large,  passively  congested. 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY    211 

Spleen:  Small,  dark,  firm. 

Kidneys:  Congested,  not  otherwise  remarkable. 

Specimens:  Lung  infarct,  liver,  kidney,  heart.     (No.  B.) 

Autopsy  Number  9.     (C.)     Patient  of  Dr.  Smith. 

Diagnosis:  Typhus  fever. 

Died  during  late  stage  of  nervous  excitement  or  early  in  that 
of  nervous  depression. 

Apparent  Cause  of  Death:  Acute  exhaustion  probably  with 
terminal  circulatory  weakness.     SHght  old  mitral  stenosis. 

Clinical  Notes 

Age  53.  The  patient  was  violently  delirious,  especially  at  night,  for 
several  days  before  death.  The  delirium  prevented  sleep  and  continued 
every  night  until  the  patient  became  exhausted.  Then  he  would  be  quieter 
for  a  time.  When  active  he  presented  the  appearance  of  delirium  tremens, 
sat  up  in  bed  grinding  his  teeth,  looked  about  wildly,  and  rolled  his  eyes. 
Apparently,  he  had  terrifying  delusions.  Mucus  collected  rapidly  in  the 
throat  and  required  frequent  attention.  The  pulse  at  first  was  rapid  and  of 
the  bounding  type.  The  breathing  was  very  rapid. 

The  afternoon  before  death,  faint,  distant,  bronchial  breathing  was 
heard  at  the  left  base  behind.  No  dulness  was  found.  The  breathing  was 
rapid  and  labored,  and  the  general  picture  was  that  of  pneumonia  in  an 
alcoholic  individual. 

Autopsy  Findings 

Body  not  emaciated.    Traces  of  rash  persist. 

Heart  Muscle:  Soft  and  dark  in  color.  Left  ventricle  in  systolic  contrac- 
tion. Right  ventricle  shghtly  dilated.  Mitral  orifice  admits  two  fingers 
with  difficulty.  Valves  slightly  shrunken  and  thickened.  No  evidence  of 
recent  damage.  Other  valves  natural.  Great  vessels  engorged  with  blood. 

Lungs:  Bloody  exudate  in  left  lower  lobe  representing  perhaps  the  first 
stage  of  pneumonic  consolidation.  Both  lungs  emphysematous  in  front. 
Right  lung  not  otherwise  remarkable. 

Liver  and  Kidneys:  Markedly  congested. 

Spleen:  Large,  dark,  confluent. 

Specimens:  Liver,  spleen,  kidney,  heart.     (No.  C.) 

Autopsy  Number  10.     (C.)     Patient  of  Dr.  Holmes. 

Diagnosis:  Typhus  fever. 

Died  during  the  postfebrile  period. 

Apparent  Cause  of  Death:  Gradual  exhaustion. 


212    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

Clinical  Notes 
Age  30.     Ill  about  five  weeks. 

Autopsy  Findings 

Postmortem  performed  twelve  hours  after  death. 

Considerable  emaciation.  No  visible  eruption.  Subcutaneous  fat  small 
in  amount. 

Heart  Muscle:  Pale.     Otherwise  normal  in  appearance. 
-     Aorta:  Shows  a  trace  of  atheroma. 

Lungs:  Bilateral  pleural  adhesions,  apparently  rather  recent.  Hypo- 
static congestion  at  bases,  greater  on  the  left  than  on  the  right. 

Liver:  Few  old  adhesions  to  surrounding  structures.  Organ  enlarged  but 
not  cirrhotic. 

Spleen:  Large,  soft,  rather  pale. 

Kidneys:  Of  normal  size,  capsules  adherent  in  places,  moderately  con- 
gested.    Otherwise  not  remarkable. 

Specimens:  Liver,  spleen,  kidney. 

A.UTOPSY  Number  12.    (S.  No.  45.)    Patient  of  Dr.  Holmes. 

Diagnosis:  Typhus  fever. 

Death  during  the  stage  of  nervous  depression. 

Apparent  Cause  of  Death:  Acute  myocardial  weakness. 

Clinical  Notes 

Serbian  soldier,  admitted  May  7. 

May  8.  White  count,  12,000. 

May  9.  (Examination  by  writer.)  On  cheeks,  nose,  and  chin  are  large 
blotches  of  haemorrhage  beneath  the  epidermis.  They  are  sharply  defined 
and  dark  red  in  color.  Traumatic  excoriations  on  back.  The  patient  is  said 
to  have  had  a  fight  in  barracks. 

The  trunk,  back,  arms,  and  legs  show  an  abundant,  macular,  purplish 
eruption.  The  patient  lies  on  the  back,  comatose,  snoring,  and  can  be 
aroused  with  difficulty.  He  breathes  through  the  mouth  rapidly  and 
deeply. 

Heart  Sounds  of  poor  quaHty,  action  rapid,  no  murmurs. 

The  pulse  is  soft  and  of  fair  volume,  but  irregular  in  force.  Blood-pres- 
sure, 90/S.-65/D. 

Lungs:  Clear  in  front  and  at  sides,  back  not  examined. 

Blood:  Haemoglobin  (Tallquist),  100  per  cent  +  +  ;  by  Sahli,  115 
percent.     Red  count,  5,0C0,000. 

May  11.  Coma  increased  and  patient  died.  - 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY    213 

Autopsy  Findings 

May  12.  Body  well  nourished. 

Heart:  Both  ventricles  much  dilated,  flabby,  and  full  of  blood.  Valves 
not  remarkable. 

Lungs:  Showed  a  few  old  adhesions. 

Intestines:  Showed  a  few  old  adhesions.  The  colon  was  enormously  dis- 
tended with  gas. 

Kidneys:  There  seemed  to  be  a  slight  excess  of  connective  tissue  and  some 
fatty  infiltration. 

Passive  Congestion  of  all  organs. 

Brain:  Very  oedema tous.     No  gross  lesion  found. 

Specimens:  Whole  heart  and  pieces  of  organs. 

Autopsy  Number  13.    (S.  No.  50.)   Patient  of  Dr.  Smith. 
Diagnosis:  Typhus  fever. 
Died  during  the  postfebrile  stage. 

Apparent  Cause  of  Death:  Gradual  exhaustion,  myocardial 
weakness. 

Clinical  Notes 

The  patient  had  a  profuse  eruption  at  the  time  of  admission.  Defer- 
vescence by  lysis  followed,  the  temperature  remained  normal  for  seven 
days  and  during  this  time  the  patient  was  apparently  improving  slowly. 
Then  fever  recurred  without  apparent  cause  and  four  days  later  the 
patient  died  with  "dyspnoea  and  distress"  which  came  on  during  the  night. 

Corneal  ulceration  appeared  at  about  the  end  of  the  febrile  period. 

Autopsy  Findings 

Body  of  man  past  middle  age,  extremely  emaciated.  Muscles  much 
wasted  and  very  dry,  but  plenty  of  blood  in  veins. 

Heart  Muscle:  Flabby.  Right  ventricle  moderately  dilated.  Valves 
natural. 

Lungs:  Bilateral  pleural  adhesions,  some  old,  others  more  recent.  Slight 
congestion  of  bases. 

Liver:  Engorged  with  blood.   Slight  fatty  degeneration. 

Spleen:  Small,  dark,  firm. 

Kidneys:  Apparently  there  is  some  fatty  infiltration  without  evidence 
of  interstitial  change. 

Specimens:  Pieces  of  organs. 


214         TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

Autopsy  Number  14.    (S.  No.  51.)    Patient  of  Dr.  Smith. 

Diagnosis:  Typhus  fever. 

Died  during  the  postfebrile  stage. 

Apparent  Cause  of  Death:  Gradual  exhaustion,  myocardial 

weakness. 

Clinical  Notes 

111  for  a  long  time.  Temperature  reached  normal  nine  days  after  admis- 
sion and  remained  there  except  for  slight  recurrences  until  the  death  of 
the  patient  nineteen  days  later. 

Autopsy  Findings 

Body  of  man  past  middle  age,  extremely  emaciated.  Muscles  extremely 
wasted.  Abdominal  wall  lies  against  spinal  column. 

Heart  Muscle:  Pale,  flabby,  no  dilatation,  valves  natural. 

Lungs:  Many  pleural  adhesions  which  appear  to  be  of  recent  formation. 
One  small  pleural  fibroma,  perhaps  tuberculous.  No  fluid  in  pleural  cavi- 
ties, no  congestion,  and  no  consolidation. 

Larynx:  Shows  slight  chronic  swelling  of  mucosa.  Vocal  cords  normal. 

Thyroid  Gland:  Not  remarkable. 

Liver:  Slight  passive  congestion. 

Spleen:  Of  normal  size,  soft. 

Kidneys:  Capsule  strips  easily.  There  is  slight  interstitial  fibrosis  and 
moderate  passive  congestion. 

Specmens:. Thyroid,  liver,  spleen,  kidney,  lung. 

Autopsy  Number  16.    (S.  No.  58.)   Patient  of  Dr. 


Diagnosis:  Typhus  fever,  acute  and  chronic,  nephritis,  en- 
larged thymus. 

Died  during  the  last  stage  of  the  febrile  period  or  imme- 
diately after  it. 

Apparent  Cause  of  Death:  Uraemia  as  a  complication. 

Clinical  Notes 

Admitted  May  16,  age  30.  Eruption  typical.  The  temperature 
dropped  by  rapid  lysis.  The  urine  was  scanty.  The  patient  died  in  a  con- 
vulsion. 

May  17.  Haemoglobin  (Sahli),  115  per  cent.  Red  count,  5,000,000. 
White  count,  15,000. 

Autopsy  Findings 

May  19.  Postmortem  performed  three  hours  after  death.  Bodyshghtly 
emaciated,  eruption  visible. 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY    215 

Heart  Muscle:  Firmly  contracted,  wall  of  left  ventricle  seems  to  be  a 
little  hypertrophied.  A  few  small  patches  of  atheroma  in  the  sinuses  of 
Valsalva.  No  other  abnormalities  seen. 

Lungs:  Pleural  cavities  nearly  obliterated  by  adhesions.  Some  of  those 
on  the  right  appear  to  be  recent,  the  others  are  old.  Posterior  margins, of 
lungs  congested. 

Thymus  Gland:  Larger  than  normal.  Adhesions  between  sternum  and 
mediastinal  contents. 

Abdominal  Cavity:  Shows  many  old  adhesions  of  omentum  to  abdominal 
wall  and  to  intestines. 

Liver:  Thickly  covered  with  old  fibrous  adhesions. 

Spleen:  Buried  in  a  mass  of  old  adhesions,  much  enlarged,  and  very  soft. 

Kidneys:  Both  much  enlarged.  Surface  of  section  gritty,  pale,  and 
grayish  in  color.  Appearance  suggests  acute  process  superimposed  on  a 
chronic  nephritis. 

Specimens:  Left  ventricle,  liver,  spleen,  kidney. 

Autopsy  Numbee  17.    (S.  No.  53.)   Patient  of  Dr.  Smith. 

Diagnosis:  Typhus  fever. 

Died  during  the  stage  of  nervous  depression. 

Apparent  Cause  of  Death:  Coma,  bronchitis,  and  pulmonary 
congestion. 

Clinical  Notes 

Admitted  May  14. 

May  15.  (Examination  and  notes  by  writer.)  Patient  lies  on  back, 
eyes  closed,  knees  drawn  up  and  apart,  breathing  rapid  and  shallow,  but 
without  effort ;  wakes  frequently  and  looks  about  anxiously  as  if  having  bad 
dreams.  There  is  a  slight  rattle  in  the  throat  and  the  patient  groans  from 
time  to  time.  The  face  is  dark  brown  and  cyanotic  as  are  also  the  lips  and 
ears.  The  conjunctivae  are  injected.  The  pupils  are  equal  and  unusually 
large. 

The  Eruption  is  chiefly  macular  but  some  of  the  spots  are  elevated  to  the 
touch.  The  color  is  brownish  purple.  The  trunk  and  arms  are  so  profusely 
covered  by  the  rash  that  no  normal  skin  can  be  seen.  There  are  many  spots 
on  the  legs,  and  a  few  on  the  backs  of  the  hands  and  feet.  There  are  a  few 
circular,  red  spots  of  uniform  size  and  smaller  than  the  head  of  a  pin.  They 
are  old  flea  bites. 

The  Heart  Action  is  rapid,  and  the  sounds  are  of  fair  quality,  but  partly 
obscured  by  rales.  The  first-sound  is  short.  The  pulse  is  regular,  of  good 
volume,  and  diminished  tension. 

Lungs:  Chest  of  barrel  type,  hyperresonant  in  front.  There  are  many 
medium  rales  in  front,  and  coarser  rales  behind,  but  no  bronchial  breathing 
or  dulness. 


216    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

Abdomen:  Shows  slight  general  sensitiveness.  The  bladder  is  distended 
to  the  umbilicus.  Urine  and  faeces  are  passed  involuntarily. 

The  Knee-jerks  are  present.  There  is  a  slight  Kernig's  sign.  The  muscles 
of  the  calves  and  thighs  are  not  sensitive.  The  neck. is  very  slightly  stiff. 

Haemoglobin,  100  per  cent  or  more.  The  color  does  not  correspond  well 
with  that  of  the  Tallquist  scale. 

Blood-pressure,  about  95/S.-80/D.,  but  variable.  Some  systolic  sounds 
are  heard  at  a  pressure  of  100  mm.  showing  variation  in  force  of  the  pulse. 
The  variation  seemed  to  be  dependent  on  the  phase  of  the  respiration. 

May  17.  Blood-pressure,  100/S.-85/D.  Breathing  easier,  cyanosis  less, 
no  rattle  in  throat,  rales  heard  only  at  the  backs.  Mildly  delirious  but 
brighter.  Haemoglobin  (Sahli),  130  per  cent.  Red  count,  5,600,000. 
White  count,  4300. 

May  21 .  Since  last  note  the  patient  has  alternately  improved  and  re- 
lapsed. He  has  been  constantly  more  or  less  delirious.  Yesterday  he  be- 
came comatose.  The  pulse  today  is  smaller  and  weaker  than  it  was.  The 
pupils  are  very  small.  The  patient  died  at  10  p.m. 

Autopsy  Findings 

Postmortem  performed  twelve  hours  after  death. 

Body  strongly  developed  and  well  nourished,  apparent  age  40  years. 
Extreme  lividity. 

Heart:  Normal  in  size,  in  systolic  contraction,  neither  ventricle  dilated, 
muscle  firm.  Otherwise  natural.  There  is  a  very  small  patch  of  atheroma- 
on  the  aorta. 

Lungs:  Congestion  slight  in  right  lung,  marked  in  the  left.  No  consolida- 
tion. The  bronchi  contain  thick,  blood-stained  mucus.  Mucous  membrane 
of  bronchi  red  and  swollen. 

Liver:  Moderately  enlarged  and  congested. 

Spleen:  Adherent  to  the  abdominal  wall  in  the  flank,  twice  the  normal 
size,  soft. 

Kidneys:  Appear  normal. 

Urine  from  bladder  contains  much  albumen,  some  pus,  a  few  red  blood- 
cells  and  casts. 

Specimens:  Whole  heart,  liver,  spleen,  and  kidney. 

Autopsy  Number  18.     (S.  No.  71.)     Patient  of  writer. 

Diagnosis:  Typhus  fever. 

Died  during  the  stage  of  nervous  depression. 

Apparent  Cause  of  Death:  Coma,  beginning  pneumonia  (?). 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 


217 


Clinical  Notes 

May  19.  Patient  transferred  today  from  another  ward,  feeble  and 
mildly  delirious.  There  was  a  profuse  purple  eruption  when  he  was  ad- 
mitted to  hospital  on  May  14. 

Heart  Sounds:  Obscured  by  rales.   Pulse  good. 


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Autopsy  Number  18.   Typhus  fever. 
Coma,  (?)  beginning  pneumonia 


Lungs:  At  the  right  base  there  is  dulness  with  diminished  breath 
sounds  and  rales.  At  the  left  base  there  are  rales,  and  at  the  angle  of  the  left 
scapula  distant  bronchial  breathing  is  heard. 

May  20.  The  patient  takes  fluid  badly  but  excretes  it  well.  He  coughs 
occasionally,  but  lacks  strength  to  spit.  The  respiration  is  very  rapid,  and 
suggests  pneumonia.  The  arms,  and  especially  the  hands,  twitch  constantly. 
The  patient  sweats  profusely  and  is  comatose  and  incontinent. 

May  21 .   Died  this  morning. 


218    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY- 

Autopsy  Findings 

May  21.  Body  of  man  of  middle  age,  well  nourished.  The  eruption  has 
faded. 

Heart:  Several  milk  patches  on  visceral  pericardium.  The  heart  is  rather 
small  and  contracted.  The  muscle  appears  normal  and  the  valves  natural. 
There  are  a  few  small  patches  of  atheroma  on  the  aorta.  The  coronary- 
orifices  are  normal. 

Lungs:  No  pleural  adhesions.  Near  the  apex  of  the  right  lower  lobe  there 
is  a  patch  of  congestion  about  three  inches  in  diameter.  There  is  no  con- 
solidation. The  bases  are  not  congested,  and  the  lungs,  otherwise,  appear 
normal. 

Abdomen:  Colon  much  distended  with  gas.  A  mass  of  old  fibrous  ad- 
hesions surrounds  the  spleen. 

Spleen:  Shows  thick  patches  of  fibrous  tissue  on  its  surface. 

Liver:  Definitely  but  slightly  cirrhotic,  and  slightly  enlarged. 

Kidneys:  Congested,  not  otherwise  remarkable. 

Specimens:  Whole  heart  and  pieces  of  organs. 

Autopsy  Number  19.  (S.  No.  81.)  Patient  of  Dr.  Smith 
and  of  writer. 

Diagnosis:  Post-typhus  parotitis  and  cellulitis  with  septi- 
caemia. 

Died  during  the  stage  of  nervous  depression. 

Apparent  Cause  of  Death:  Parotitis  and  septicaemia. 

Clinical  Notes 

Austrian  soldier.  Transferred  from  another  ward  in  the  later  stages  of 
typhus  fever.  Previously,  he  had  a  definite  rash  which  has  now  disap- 
peared. 

May  19.  The  patient  is  extremely  thin.  Both  cheeks  are  much  swollen, 
hard,  and  moderately  sensitive,  causing  much  pain  and  making  swallowing 
very  difficult. 

May  21 .  Increased  fever.  Fluctuation  can  be  definitely  felt  on  the  right 
cheek  in  front  of  the  ear.  An  incision  was  made  by  Dr.  Smith  under 
chloroform  anaesthesia  and  several  ounces  of  thick  pus  were  evacuated. 
White  count,  9100. 

May  22.  The  temperature  remains  high  and  the  pulse  rapid.  There  is 
little  discharge  from  the  incision  on  the  right  and  the  swelling  has  increased. 
Therefore  another  incision  was  made  at  the  angle  of  the  jaw  on  the  same 
side  but  very  little  pus  was  found.  A  third  incision  was  then  made  on  the 
left  side  below  the  ear  and  15  to  30  cc  of  thick  pus  were  evacuated. 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 


219 


May  23.  Today  the  skin  and  conjunctivae  showed  slight  jaundice.  The 
patient  has  been  practically  without  nourishment  for  several  days.  A  little 
was  given  through  a  nasal  tube.   Urine,  sp.  gr.  1018,  bile  present. 

May  24-  The  swelling  under  the  chin  which  began  a  few  days  ago  has 
increased  in  spite  of  the  incisions  over  both  parotids.   The  temperature  is 


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Autopsy  Number  19.   Typhus  fever. 
Parotitis  and  septicaemia 

very  high  and  breathing  is  diflficult.  Under  local  anaesthesia  Dr.  Smith 
made  a  deep  incision  under  the  chin  but  the  amount  of  pus  evacuated  was 
small.  The  tissue  was  firm  and  oedematous.  The  patient  died  at  7.45  p.m* 

Autopsy  Findings 

Postmortem  performed  thirteen  hours  after  death. 
Body  of  man  of  about  35  years  of  age.  Extremely  emaciated. 
Heart:  Slight  excess  of  clear  yellowish  fluid  in  the  pericardial  sack.    The 
organ  is  of  normal  size,  and  firmly  contracted.   The  muscle  is  pale,  and 


220    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

rather  soft.  On  one  curtain  of  the  tricuspid  valve  and  on  the  wall  of  the 
heart  above  it  are  patches  of  oedema  with  a  little  extravasation  of  blood. 
The  valves  appear  otherwise  normal. 

Lungs:  Appear  normal.     There  is  little  if  any  oedema. 

Abdomen:  Intestines  moderately  distended  with  gas. 

Liver:  Rather  small.  The  surface  of  section  is  shiny  and  stained  with 
bile.  The  markings  are  indistinct. 

Spleen:  Much  enlarged  and  very  soft. 

Kidneys:  The  left  kidney  is  about  twice  the  normal  size.  The  capsule 
strips  easily.  The  surface  of  section  shows  pale  streaks  in  the  cortical  region 
and  the  markings  there  are  indistinct. 

The  right  kidney  is  about  one-half  the  normal  size,  and  is  moderately 
congested,  but  otherwise  normal  in  appearance. 

Larynx:  Mucous  membrane  slightly  swollen  and  injected  but  not  o ede- 
matous. 

Specimens:  Pieces  of  organs. 

Autopsy  Number  20.   (S.  No.  84.)     Patient  of  writer. 

Diagnosis:  Typhus  fever. 

Died  during  the  state  of  defervescence. 

Apparent  Cause  of  Death:  Chronic  myocardial  degeneration. 

Clinical  Notes 

May  26.  The  patient  is  an  old  man  sent  yesterday  from  another  ward. 
He  is  well  developed,  but  poorly  nourished.  He  is  mentally  clear. 

The  face  is  not  flushed.  The  conjunctivae  are  shghtly  injected.  The 
pupils  are  equal  and  of  normal  size.  The  tongue  shows  a  sHght,  white  coat. 
The  throat  is  negative  except  for  shreds  of  thick  mucus  adherent  to  it. 

The  Eruption  is  small,  macular,  and  purphsh-pink.  Most  of  the  spots 
disappear  completely  on  pressure.  The  spots  are  best  seenon  the  inner  sur- 
faces of  the  arms  and  wrists  and  on  the  sides  of  the  chest  where  they  are 
numerous.  There  are  few  or  none  in  other  parts. 

The  Heart  Action  is  rapid  and  regular.  The  second-sounds  are  of  good 
quality.  The  first-sound  is  short  and  valvular,  and  the  pulse  small  and 
weak.  The  arteries  are  palpable.  Blood-pressure,  75/S.-60/D. 

The  Abdomen  is  fiat,  and  shows  sHght  general  sensitiveness.  The  spleen 
is  not  palpable  and  splenic  dulness  is  not  increased. 

The  knee-jerks  are  present.  There  is  no  sensitiveness  of  the  leg  muscles, 
and  no  Kernig's  sign.  The  neck  is  not  stiff.   Haemoglobin,  85  per  cent. 

Date  (?).  The  patient  has  vomited  a  little.  He  dislikes  Uquids,  but  eats 
bread. 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 


221 


At  midnight  the  patient  was  given  something  to  drink  and  seemed  all 
right.  At  12.30  A.M.  when  the  nurse  returned  to  the  ward  to  get  something 
the  patient  made  a  sudden  motion  and  died  immediately. 

Autopsy  Findings 

Postmortem  performed  ten  hours  after  death.  Body  emaciated. 
Heart:  Normal  in  size  and  not  dilated.    Muscle  brown  and  flabby. 
Cardiac  vessels  not  tortuous.    Slight  old  thickening  of  the  mitral  valve, 


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Autopsy  Number  20.   Typhus  fever.   Chronic 
myocardial  degeneration 

the  orifice  of  which  admits  two  fingers.  The  other  valves,  the  aorta,  and  the 
coronary  arteries  are  natural. 

Lungs:  Many  pleural  adhesions  on  left  side.  The  back  of  the  left  lung  and 
especially  the  apex  of  the  lower  lobe  is  dark  in  color,  and  on  section  a  haem- 
orrhagic  fiuid  exudates.  The  lung  feels  leathery.  The  apex  of  the  left  lung 


222    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

remains  distended  and  feels  like  a  cyst.  On  cutting  it  a  clear  fluid  exudates. 
On  the  right  side  there  are  fewer  adhesions  than  on  the  left  and  the  lung  is 
less  congested  than  the  left. 

Abdomen:  Intestines  moderately  distended  but  otherwise  normal  in 
appearance. 

Liver:  Of  normal  size.  Surface  of  section  pale  brown  in  color  and 
greasy.  It  is  pitted  here  and  there  and  shows  yellowish  spots.  (Slight 
fibrosis  and  fatty  changes.) 

Spleen:  Firmly  adherent  to  surrounding  structures.  Capsule  nearly 
covered  with  patches  of  old  fibrous  tissue.  Organ  much  enlarged.  Pulp 
almost  fluid. 

Kidneys:  The  left  is  large,  and  its  markings  are  vague  and  confused  by 
whitish  streaks  and  spots.  The  right  is  smaller  than  the  left,  and  is  similarly 
abnormal  in  appearance  but  to  a  less  degree. 

Specimens:  Whole  heart  and  pieces  of  organs. 

Autopsy  Number  21.     Patient  of  Dr.  Smith. 
Diagnosis:  Typhus  fever. 
Died  during  the  stage  of  nervous  depression. 
Apparent  Cause  of  Death:  Coma  and  diarrhoea  with  terminal 
circulatory  collapse. 

Clinical  Notes 

On  admission  the  patient  had  a  typical  and  very  profuse  rash.  He  died 
three  days  later.  The  nurse  said  that  the  patient  was  comatose  from  the 
time  of  admission,  that  the  throat  was  covered  with  dry,  hard  mucus,  and 
that  there  was  cough,  incontinence,  and  diarrhoea,  and  that  the  patient  had 
to  be  fed  with  a  nasal  tube.  He  was  very  cyanotic,  but  breathed  easily. 
The  legs  on  the  morning  before  death  were  icy  cold.  The  pulse  remained 
good  until  6  P.M.  when  it  became  very  feeble.  The  patient  died  an  hour  later, 
three  days  after  admission. 

Autopsy  Findings 

Body  of  man  apparently  about  30  years  of  age.  Well  developed,  poorly 
nourished.   No  rash  visible.   Many  sudamina. 

Heart:  Not  dilated,  muscle  firm  and  normal  in  appearance.  There  is 
sKght  fibrous  thickening  of  mitral  valve  which  admits  two  fingers.  The 
other  valves  are  normal  in  appearance.  The  coronary  openings  are  normal. 
There  are  a  few  small  yellowish  spots  on  the  inner  surface  of  the  aorta. 

Lungs:  Normal  in  appearance.  No  congestion. 

Abdomen:  The  intestines  appeared  normal  externally. 

Liver:  On  section  the  markings  are  indistinct.  The  color  is  rather  pale 
brown. 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY    223 

Spleen:  Adherent  to  surrounding  structures  and  covered  with  fibrous 
adhesions.   It  is  shghtly  enlarged  and  rather  soft. 

Kidneys:  Normal  in  size;  capsule  strips  easily.  On  section  markings  in- 
distinct. Cortex  shows  yellowish  mottling. 

Specimens:  Whole  heart  and  pieces  of  organs. 

Autopsy  Numbek  22.     Patient  of  Dr.  Smith. 
Diagnosis:  Typhus  fever. 

Died  during  the  stage  of  defervescence  or  later. 
Apparent  Cause  of  Death:  Late  circulatory  weakness. 

Clinical  Notes 

The  eruption  was  fading  at  the  time  of  admission.  The  nurse  says  that 
at  this  time  the  patient  was  rather  cyanotic  and  the  pulse  scarcely  palpable, 
and  that  it  improved  later,  but  was  never  good.  The  patient  gained  a  little 
at  first  and  took  food  well  until  the  last  day.  The  stools  were  loose  and 
there  was  slight  diarrhoea.  There  was  quiet,  muttering  delirium.  The  pa- 
tient did  not  look  as  if  dangerously  sick.  On  the  last  day  of  life  three  saUne 
enemata  were  given  and  all  were  retained.  The  patient  got  very  cold  six 
hours  before  death  and  died  at  11  p.m. 

Autopsy  Findings 

Body  of  man  apparently  about  35  years  of  age.  Well  developed  and 
nourished.  Much  post-mortem  discoloration. 

Heart:  Relaxed;  muscle  very  flabby.  Several  small  milk  patches  on 
epicardium.  Edges  of  mitral  valve  show  slight  fibrous  thickening.  The 
orifice  easily  admits  two  fingers.  The  other  valves  appear  normal. 

Lungs:  Pleural  cavities  normal  in  appearance.  Anterior  surface  of  lungs 
natural.  Marked  acute  congestion  posterially  and  especially  at  bases.  No 
consolidation  or  atelectasis. 

Abdomen:  The  intestines  and  stomach  are  distended  with  gas. 

Liver:  Normal  in  size  and  consistence,  moderately  congested. 

Spleen:  Few  fibrous  adhesions.  The  organ  is  several  times  the  normal 
size  and  very  soft. 

Kidneys:  Markedly  congested;  otherwise  natural  in  appearance. 

Specimens:  Whole  heart,  and  pieces  of  organs. 

Autopsy  Numbee  23.     (S.  No.  95.) 
Diagnosis:  Typhus  fever. 
Died  during  the  stage  of  nervous  depression. 
Apparent  Cause  of  Death:  Coma,  with  cerebrospinal  inflam- 
matory phenomena  and  excess  of  cerebrospinal  fluid. 


224    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

Clinical  Notes 

June  12.  Turkish  prisoner,  age  40.  Admitted  last  night.  Does  not  know 
how  many  days  ill.     Condition  good. 

Physical  Examination:  The  patient  looks  comfortable,  breathes  through 
the  mouth,  respiration  rapid  and  shallow,  nostrils  move  with  respiration. 
He  is  semicomatose,  but  replies  to  questions  when  roused.  There  is  oc- 
casional dry  cough. 

The  pupils  are  equal  and  very  small.  The  conjunctivae  are  deeply  in- 
jected. The  tongue  is  brown,  fissured,  and  dry.  The  pharynx  and  soft 
palate  are  red  and  glazed,  with  sticky  mucus  adherent. 

The  forehead  and  cheeks  are  flushed.  There  is  a  slight  flush  on  the  neck 
and  on  the  upper  sternum.  The  ears  are  not  flushed. 

The  Eruption  is  seen  on  the  lower  part  of  the  neck.  It  is  profuse  over  the 
front  and  sides  of  the  chest,  on  the  upper  abdomen  and  on  the  back,  less 
abundant  on  the  lower  abdomen  and  upper  arms,  scanty  on  the  forearms, 
legs,  and  hands,  and  slightly  more  marked  on  the  feet.  It  consists  of  irregu- 
lar, ill-defined  macules,  some  large  and  some  small.  The  color  is  purple  with 
a  pinkish  tinge. 

Heart:  Size  apparently  normal,  action  rapid,  regular.  The  aortic  second- 
sound  is  of  fair  quality,  the  pulmonic  second-sound  is  rather  faint,  and 
the  first-sound  at  the  apex  has  a  valvular  quality.  The  pulse  is  full  and 
of  the  bounding  type.  The  tension  is  low.  The  blood-pressure  is  90/S.- 
50/D. 

Lungs:  There  is  no  dulness  or  bronchial  breathing.  Many  coarse,  dry 
rales  are  heard  and  at  the  base  of  the  right  axilla  some  fine  moist  rales. 

The  Abdomen  is  soft,  and  there  is  slight  general  sensitiveness  with  volun- 
tary spasm.  The  liver  and  spleen  are  not  palpable  but  the  splenic  dulness  is 
much  increased. 

The  muscles  of  the  neck  are  not  sensitive  but  the  neck  can  be  bent  for- 
ward only  a  little.  Rotation  is  free.  The  muscles  of  the  thighs  and  calves  are 
sensitive  to  firm  pressure.  Those  of  the  arms  are  not  so.  The  knee-jerk  is 
sluggish  on  the  right  and  is  not  obtained  on  the  left.  Kernig's  sign  is  well 
marked.  Haemoglobin  (Tallquist),  100  per  cent. 

June  15.  The  patient's  color  is  becoming  dusky.  He  never  sleeps.  Digi- 
tahs  has  been  administered  subcutaneously  because  the  patient  takes 
medicine  badly.  He  took  food  well  the  first  day,  but  since  then  has  taken 
little  food  or  water. 

He  coughs  a  little  but  raises  nothing.  There  are  a  few  fine  rales  at  the 
right  base  and  many  coarse  and  medium  rales  in  the  same  region  and  extend- 
ing upward  to  the  mid-scapula. 

Heart  Sounds  are  of  fair  quality.  The  blood-pressure  at  11.30  a.m.  was 
100/S.-80/D. 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 


225 


The  eruption  is  fading.  Some  of  the  spots  are  brown  and  others  are 
purple. 

June  16.  In  the  evening  the  patient  became  restless  and  made  peculiar 
movements  with  the  arms.  There  was  tonic  spasm  of  the  muscles  of  the  arms, 


A^toF 


CUNICAL  CHART    , 

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MMC.&e.Tils'.'^iiSl . DATE  June  11,  191S.. 

MEDICAL   RECORD   BOOK,  VOL  .   DISEASE    Typ  h  aS— feVer. 


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Coma    and  cerebrospinal  inflamma- 
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and  the  fingers  were  clenched  but  not  in  the  position  of  tetany.  The  knee- 
jerks  were  absent. 

June  17.   The  patient's  color  has  become  almost  leaden  but  the  pulse 
continues  relatively  good.  The  respiration  is  more  rapid. 

The  spasms  of  the  arms  have  ceased,  but  stiffness  of  the  neck  has  in- 
creased. Neither  forward  bending  of  the  head  nor  rotation  are  now  possible 
without  pain.   The  patient  is  becoming  comatose.   The  lungs  show  a  few 
rales. 
•  The  patient  died  at  noon. 


226    TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 

Autopsy  Findings 

The  muscles  are  not  dry.  Much  blood  escaped  from  the  great  vessels 
when  the  heart  was  removed.  The  subcutaneous  fat  is  moderate  in  amount 
and  very  tough  and  dry. 

Heart:  Firmly  contracted;  muscle  firm  and  normal  in  appearance. 

Lungs:  On  the  surface  of  the  left  lung  at  the  apex  are  a  few  fresh  adhe- 
sions and  several  small  patches  of  blood-stained  fibrin  are  adherent  to  the 
lateral  and  posterial  aspects  of  the  lower  and  middle  portion.  The  lung  tis- 
sue is  leathery  and  pinkish  on  section.  There  is  a  small  amount  of  oedema 
not  confined  to  the  bases.  The  bronchial  mucosa  is  moderately  reddened 
but  not  swollen.  There  is  a  little  viscid  exudation  in  the  larger  tubes.  The 
condition  of  the  right  lung  is  practically  the  same  as  that  of  the  left. 

Abdomen:  The  intestines  are  not  distended  and  are  normal  in  appearance 
externally. 

Liver:  Yellowish,  with  nutmeg  markings. 

Spleen:  Slightly  enlarged,  rather  soft. 

Kidneys:  Appear  normal. 

Brain:  On  opening  the  skull  a  large  quantity  of  fluid  escaped.  There  was 
some  blood  with  it  which  may  have  come  from  the  veins  or  sinuses  as  a 
result  of  removing  the  skull. 

Thepia  is  markedly  oedematous  in  the  region  of  the  motor  area.  The 
oedema  is  haemorrhagic  and  particularly  so  along  the  course  of  the  arteries. 
There  seemed  to  have  been  small  haemorrhages  in  this  region.  These 
changes  were  more  marked  on  the  left  side  than  on  the  right. 

Specimens:  Whole  heart,  and  pieces  of  organs,; 

Autopsy  Numbee  24.     (S.  No.  94.) 
Diagnosis:  Typhus  fever. 
Died  during  the  stage  of  nervous  depression. 
Apparent  Cause  of  Death:  Exhaustion  and  circulatory  insuffi- 
ciency of  vascular  origin. 

Clinical  Notes 

June  12.  The  patient  arrived  yesterday  at  10  p.m.  having  travelled  some 
distance  on  the  train.  He  was  too  sick  to  be  communicated  with  satisfac- 
torily. At  the  time  of  admission  the  linibs  were  cold,  the  pulse  of  poor  qual- 
ity, and  the  heart  sounds  faint.  Brandy  was  administered  by  mouth,  coffee 
by  rectum,  and  heaters  were  applied. 

The  face  is  flushed  and  the  conjunctivae  are  injected.  The  pupils  are  of 
pin-point  size.  The  tongue  is  dry  with  a  brownish  coat.  The  soft  palate  is 
red  and  dry.  The  patient  breathes  through  the  mouth  rapidly  and  super- 
ficially. 


TYPHUS  FEVER  -FATAL  C ASES  —  AUTOPSY    227 

The  Eruption  is  profuse  on  the  chest  and  abdomen.  Less  so  on  the  arms, 
back,  and  legs.   It  is  macular  in  form  and  purple  in  color. 

The  Heart  Action  is  regular.  The  aortic  second-sound  is  slightly  accen- 
tuated and  louder  than  the  pulmonic  second-sound.  The  first-sound  is 
sharp  and  louder  than  the  second  at  the  apex.  Blood-pressure,  105/S.- 
80/D. 

The  Lungs  are  clear  except  for  a  few  rales  at  the  right  base. 

The  Abdomen  is  soft.  The  bladder  is  overdistended.  (Catheterization 
was  required  daily.) 

June  Id.  At  noon  the  patient  became  almost  pulseless.  Almost  imme- 
diately after  a  subcutaneous  injection  of  ether  the  pulse  returned.  A  few 
minutes  later  the  patient  swallowed  a  little  brandy.  Immediately  after 
that  the  blood-pressure  was  100/S.-90/D.  Normal  salt  solution,  600  cc, 
was  then  given  intravenously.  During  the  injection  the  heart  sounds  be- 
came louder  and  the  aortic  second-sound  became  accentuated.  Imme- 
diately after  the  injection  the  first-sound  was  short  but  of  fair  quality,  and 
the  others  were  good .  The  second-sounds  were  about  equal,  the  pulse  was 
full,  and  the  blood-pressure  was  110/S.-90/D.  At  4.45  p.m.,  about  fifteen 
minutes  after  the  infusion,  the  patient  had  a  shght  rigor  which  seemed  to 
affect  his  condition  little.  When  a  nurse  returned  a  few  minutes  later,  the 
patient  was  again  almost  pulseless.  After  that  he  became  very  delirious 
and  tried  to  get  out  of  bed.  In  a  short  time  he  became  quiet  again  and  the 
pulse  and  heart  sounds  were  once  more  of  good  quality. 

The  patient  has  been  having  diarrhoea  and  has  taken  little  food  for  two 
days.  He  is  rapidly  losing  flesh  and  strength. 

June  16.  During  the  night  the  patient  again  became  pulseless  and  360 
cc.  of  salt  solution  were  given  intravenously  but  the  circulation  improved 
little.  The  injection  therefore  was  discontinued.  The  patient  then  received 
ether  subcutaneously  and  the  pulse  improved. 

This  morning  he  became  pulseless  again.  The  respiration  was  very 
rapid.  The  patient  was  conscious  but  very  weak. 

Bronchial  breathing  of  moderate  intensity  and  a  few  rales  were  heard  at 
the  right  base.  The  lungs  were  otherwise  negative. 

The  pulse  remained  impalpable  or  nearly  so  throughout  the  day.  In  the 
morning,  in  spite  of  the  had  quality  of  the  pulse,  the  heart  sounds  were  loud 
and  clear.    The  patient  died  at  5  p.m. 

Autopsy  Findings 

The  postmortem  was  performed  sixteen  hours  after  death. 

Body  of  man  apparently  about  45  years  of  age,  much  emaciated,  muscles 
not  dry.  Much  blood  escaped  from  the  great  vessels  when  the  heart  was 
removed.  Subcutaneous  fat  moderate  in  amount.  Very  tough  and  dry. 


228 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 


Heart:  Firmly  contracted,  muscle  firm  and  normal  in  appearance,  valves 
natural,  coronary  openings  normal. 

Lungs:  The  right  lung  in  front  and  the  left  lung  at  the  lower  part  pos- 
terially  are  bound  to  the  chest  wall  by  adhesions  which  appear  neither 
recent  nor  very  old.  The  left  lung  shows  a  moderate  degree  of  passive  con- 


Au.topsv*2.4- 


CUNICAL  CHARTv 


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Autopsy  Number  24.   Typhus  fever. 
Exhaustion  and  circulatory- 
insufficiency 


gestion  especially  at  the  base.  The  right  lung  shows  a  large  area  of  haem- 
orrhagic  oedema  in  the  central  portion  with  increased  consistency  but  no 
consolidation.  The  lower  portion  behind  is  atelectatic. 

Abdomen:  The  cavity  appears  normal. 

Liver:  On  section  shows  yellowish  mottling. 

Spleen:  Slightly  enlarged,  rather  soft. 

Kidneys:  Appear  natural. 

Specimens:  Whole  heart  and  pieces  of  organs. 


TYPHUS  FEVER  — FATAL  CASES  —  AIJTOPSY  229 

Autopsy  Numbee  25.     (S.  No.  90.) 
Diagnosis:  Typhus  fever. 
Died  during  the  postfebrile  stage. 

Apparent  Cause  of  Death:  Gradual  exhaustion;  inhalation 
pneumonia. 

Clinical  Notes 

The  patient  was  admitted  to  another  ward  on  June  3.  He  had  no  erup- 
tion then.   It  was  first  noticed  on  June  7. 

June  9.  The  patient  refused  to  take  medicine. 

Digitahs,  0.00065  gm.,  was  administered  every  four  hours  subcutane- 
ously. 

June  11.  The  patient  breathes  rapidly  but  easily  and  has  occasional  dry 
cough.  He  is  mentally  apathetic  and  his  replies  to  questions  seem  inco- 
herent. The  face  is  not  definitely  flushed  but  the  ears  are  red.  The  con- 
junctivae are  not  injected.  The  pupils  are  equal  and  of  medium  size.  The 
lids  of  the  right  eye  remain  practically  closed  but  there  is  no  apparent 
muscular  paralysis.  The  tongue  shows  a  heavy  brownish  coat.  The  skin  of 
the  body  is  moderately  pigmented,  especially  on  the  front  of  the  chest. 

Eruption:  On  the  shoulders,  the  arms,  the  backs  of  the  hands  and  feet, 
and  the  sides  of  chest  there  are  many  purple  macules  irregular  in  shape, 
varying  in  size.  The  abdomen  is  profusely  covered  with  maculopapules. 
On  the  back  and  thighs  there  are  a  number  of  reddish-purple  macules.  The 
lower  legs  are  free  from  spots  but  they  present  numerous  recent  scars  and 
crusted  ulcers,  apparently  syphilitic. 

The  Heart  Action  is  regular,  the  sounds  faint,  the  cardiac  dulness  di- 
minished, and  the  pulse  of  low  tension.  Blood-pressure,  95 /S. -75 /D. 

The  Lungs  are  hyperresonant  at  the  right  base.  There  are  many  rales 
and  the  breath  sounds  are  diminished.  There  are  a  few  rales  at  the  left 
base  but  no  bronchial  breathing. 

The  Abdomen  is  flat  and  shows  slight  general  sensitiveness  but  no  spasm. 

The  Spleen  is  not  palpable  but  the  splenic  dulness  is  increased. 

The  knee-jerks  are  sluggish.  The  neck  is  slightly  stiff  and  sensitive 
behind.  The  left  leg  can  be  raised  perpendicularly  without  pain,  but  an 
attempt  so  to  raise  the  right  leg  causes  slight  pain.  The  calves  are  not 
sensitive,  but  the  thigh  muscles  are  so.  Haemoglobin,  90  per  cent. 

June  12.  The  patient  began  to  be  delirious  at  night  on  June  7  and  has 
been  so  ever  since.  He  has  been  very  difficult  to  feed  and  has  taken  little 
nourishment.  His  condition  is  becoming  serious.  He  was  fed  with  a  nasal 
tube  last  night.  His  mouth  is  very  dirty  and  he  refuses  to  have  it  cleaned. 
Evacuations  are  involuntary. 

June  15.  There  is  slight  improvement  today.  The  rash  is  fading  and  has 
become  purple  and  brown;  it  is  still  clearly  visible.  Nasal  feeding  has  been 


230 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY 


continued  with  considerable  difficulty.  The  patient  is  now  beginning  to 
drink  a  little  liquid  when  given  with  bread.  There  is  considerable  muttering 
delirium  this  afternoon. 

At  night  the  patient  is  very  delirious.  He  has  taken  so  little  liquid  that 
360  cc  of  salt  solution  were  given  intravenously  at  midnight.  One  hour 


NAME..iSerieS.*  9  01. 

MEDICAL  RECORD  BOOK.  VOL 


CUNICAL  CHART 

WARD BED  NO     _    _    .DATE  Julie.3>19JA 

.  PAGE DISEASE  Typhus    feVftt". 


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Autopsy  Number  25.    Typhus  fever.    Inhalation 
pneumonia 


and  a  haK  after  the  infusion  he  had  a  severe  chill.  The  salt  solution  had 
been  freshly  prepared  with  care. 

June  17.  The  delirium  is  quieter  today,  and  the  patient  weaker.  A 
small  abscess  on  the  buttock  was  opened  yesterday,  and  today  another 
appeared  on  the  thigh. 

In  the  afternoon  the  patient  was  very  weak  and  the  pulse  was  of  poor 
quality.  Salt  solution,  450  cc,  was  given  intravenously.  Fifteen  minutes 
later  the  delirium  increased  and  the  patient  had  a  chill.   A  small  dose  of 


TYPHUS  FEVER  — FATAL  CASES  —  AUTOPSY    231 

morphine  was  given  subcutaneously  after  which  the  pulse  improved  much 
and  the  patient  slept  well.  The  pulse  remained  good  in  the  evening.  The 
salt  solution  was  used  because  the  patient  was  taking  practically  nothing  by 
mouth  and  fought  off  attempts  to  feed  him  with  the  nasal  tube. 

June  18.  Thismorning  the  patient's  condition  is  about  the  same.  He  is 
delirious,  apathetic,  and  weak,  but  the  pulse  is  of  fair  quality.  He  takes 
nourishment  better. 

Corneal  ulceration  began  several  days  ago. 

June  19.  The  patient  is  semicomatose  and  the  pulse  extremely  bad. 

June  20.  For  the  last  two  days  the  patient's  condition  has  been  getting 
worse.  Symptoms  suggested  pulmonary  lesions,  but  no  definite  signs  have 
been  found.  The  lungs  were  not  examined  yesterday. 

The  abscess  of  the  buttock  became  a  slough  and  is  increasing. 

The  stiffness  of  the  neck  continues  slight  this  morning  and  the  patient  is 
practically  pulseless  and  comatose.   He  died  about  9  a.m. 

Autopsy  Findings 

Postmortem  performed  one  hour  after  death.    Body  much  emaciated. 

Heart:  There  is  a  milk-patch  on  the  anterior  surface  of  the  heart.  The 
left  ventricle  is  firmly  contracted.  The  right  ventricle  is  flabby  and  perhaps 
a  Kttle  dilated.  The  heart  muscle  is  apparently  in  good  condition.  The 
aortic,  mitral,  and  tricuspid  valves  show  slight  fibrous  thickening.  There 
are  a  few  minute  yellowish  spots  on  the  aorta. 

Lungs:  The  left  pleural  cavity  contains  about  30  cc.  of  pus.  The 
pleural  surface  of  the  lung  is  cloudy  and  shows  several  small  patches  of 
fibrin.  The  right  pleural  cavity  contains  no  pus  but  the  surface  of  the  lung 
is  like  that  of  the  left  except  that  the  changes  are  less  marked.  In  both 
lungs  are  numerous  small,  hard  nodules,  some  of  which,  on  section,  yield 
pus.  At  the  left  base  there  is  atelectasis.  In  the  right  lung  a  bright  red, 
narrow  area  of  consolidation  follows  the  posterior  margin. 

Abdomen:  The  intestines  appear  normal  externally. 

Liver:  Shows  slight  nutmeg  markings. 

Spleen:  Firm,  and  slightly  enlarged. 

Kidneys:  Capsules  adherent  in  places,  cortex  variable  in  width,  markings 
indistinct,  color  rather  pale. 

Specimens:  Pieces  of  organs. 


TYPHUS  FEVER,  FATAL  CASES 
NO  AUTOPSY 

Series  Number  87.     Patient  of  Dr.  Holmes. 
Diagnosis:  Typhus  fever. 
Died  during  the  stage  of  nervous  depression. 
Apparent  Cause  of  Death:    Severe  toxaemia  with  general 
sjrmptoms. 

Clinical  Notes 

A  Russian  physician,  admitted  May  21.  A  slight  eruption  was  first 
observed  on  that  day. 

May  27 .  Physical  Examination:  The  apparent  age  is  about  23.  The 
patiejnt  hes  on  the  back  propped  up.  He  is  conscious  but  the  mind  is 
clouded.  The  eyes  are  closed,  the  respiration  is  rapid  and  shallow.  The 
cheeks  and  eyelids  are  brightly  flushed  and  the  ears  are  bright  red.  The 
arms  twitch  occasionally,  the  hands  move  aimlessly  and  pick  at  the  bed- 
clothes. 

The  eruption  is  profuse  on  the  chest,  and  dull  red  in  color.  The  color 
partly  disappears  on  pressure.  The  spots  are  irregular  in  size  and  shape. 
Most  of  them  are  macular  but  on  very  close  inspection  a  few  are  seen  to  be 
slightly  elevated.  The  elevation  is  more  easily  appreciated  by  palpation. 
The  rash  is  clearly  seen  on  the  backs  of  the  hands,  and  is  abundant  on  the 
arms,  abdomen,  and  legs.  On  the  abdomen  are  a  few  maculopapules  which 
are  darker  red  and  more  elevated  than  the  others.  From  these  the  color 
does  not  disappear  on  pressure.  The  rash  as  a  whole  is  beginning  to  assume 
a  purple  tinge. 

The  Heart  Action  is  rapid  and  regular.  The  first- sound  is  faint  and  the 
second-sounds  are  accentuated.  The  pulse  is  large  and  of  the  bounding 
type. 

Lungs:  No  rales  are  heard  in  front.  The  backs  were  not  examined. 
There  is  an  occasional  cough  like  that  of  bronchitis. 

June  1 .  The  patient's  condition  has  been  critical  for  several  days.  The 
respiration  is  very  rapid  and  the  pulse  is  very  rapid  and  of  poor  quality. 
There  is  shght  cyanosis.  When  the  patient  coughs  there  is  rattHng  in  the 
throat  but  he  is  unable  to  raise  anything. 

Three  days  ago  he  grabbed  his  chart  and  carefully  examined  it.  Yester- 
day he  was  too  sick  to  do  this.  He  lies  most  of  the  time  with  eyes  closed 
and  when  approached  looks  nervously  from  side  to  side. 

232 


TYPHUS  FEVER  — FATAL  CASES  — NO  AUTOPSY   233 

The  chin  twitches  most  of  the  time  and  the  other  muscles  of  the  face 
move  continually.  The  hands  move  convulsively  and  in  a  futile  manner. 

The  eruption  is  purple  and  is  beginning  to  fade.  The  bases  of  the  lungs 
are  free  from  rales.  There  is  no  dulness  or  bronchial  breathing.  Nourish- 
ment is  taken  fairly  well.   There  is  considerable  perspiration. 

Abdominal  distention  is  now  very  marked.  The  colon  can  be  felt 
through  the  abdominal  wall.  The  distention  can  be  reduced  temporarily 
by  enemata  and  the  pulse  rate  then  falls  but  the  distention  returns  in  a 
short  time  and  then  the  pulse  rate  rises  again.  The  temperature  remains 
high. 

June  2.   The  patient  died  last  night. 

Series  Number  21.     Patient  of  Dr.  Holmes. 
Diagnosis:  Typhus  fever. 
Died  during  the  stage  of  nervous  depression. 
Apparent  Cause  of  Death:   Pulmonary  oedema,  sudden  as- 
phyxia. 

Clinical  Notes 

May  1 .  Present  Illness:  A  Serbian  officer,  said  to  have  been  ill  six  days 
before  admission.  He  complains  of  pain  around  the  eyes  and  in  the  back  of 
the  head,  but  not  in  the  legs.  There  is  cough  and  a  little  expectoration. 

Physical  Examination:  The  apparent  age  is  about  35.  The  patient  is 
well  developed  and  nourished.  The  face  is  much  tanned,  the  ears  are  red, 
and  the  hands  are  slightly  so.  The  tongue  shows  a  white  coat.  The  con- 
junctivae are  not  injected.  The  pupils  are  equal  and  of  normal  size. 

The  Eruption  is  profuse  and  consists  of  pink  macules  on  chest,  abdomen, 
and  arms.  The  hands,  face  and  neck  are  free  from  spots. 

The  Heart  Action  is  rapid  and  regular.  The  sounds  are  of  good  quality 
and  there  are  no  murmurs.  A  few  coarse  rales  are  heard  at  the  apices 
behind. 

The  Abdomen  is  negative.  The  spleen  is  not  palpable  and  splenic  dulness 
is  not  increased. 

The  Neck  is  slightly  stiff.  There  is  a  slight  Kernig's  sign  associated  with 
muscular  spasm  but  no  pain.  The  calves  are  not  tender. 

May  3.  The  diazo-reaction  is  mildly  positive. 

May  5.  The  severity  of  the  illness  is  increasing.  The  patient  is  men- 
tally dull  and  confused  but  recognizes  people. 

There  was  epistaxis  today,  moderate  in  amount. 

The  expectoration  is  considerable  in  quantity  and  very  tenacious.  The 
breathing  is  rapid  and  shallow.  Many  rales,  most  of  which  are  of  the  coarse, 
dry  variety,  are  scattered  throughout  the  lungs. 


234       TYPHUS  FEVER  — FATAL  CASES— NO  AUTOPSY 

The  rash  is  fading  and  turning  brown. 

Blood-pressure,  90/S -55/D.  Haemoglobin,  85  per  cent. 

May  7.  There  is  an  occasional  spasm  of  hiccough.  The  patient  is 
cyanotic.  The  breathing  is  rapid  and  makes  a  whistling  sound  at  the  nose. 
The  nostrils  move  with  respiration  and  there  is  a  rattle  in  the  throat.  The 
cheeks  are  flushed.  The  forehead,  which  was  very  white  on  admission,  is 
now  slightly  pigmented. 

The  heart  sounds  are  obscured  by  coarse  rales.  Blood-pressure,  110/S.- 
55 /D.  The  patient  takes  food  badly  but  water  and  lemonade  freely. 

May  9.  This  afternoon,  in  the  absence  of  the  physician  in  charge  of  the 
ward,  the  patient  was  reported  to  me  as  being  in  a  dangerous  condition. 
When  seen  within  a  few  minutes  he  was  found  gasping  and  unconscious  but 
with  a  full,  strong  pulse  which  was  not  rapid.  There  was  a  loud  rattle  in  the 
throat.  The  patient  was  quickly  turned  on  his  side  and  the  jaws  held  open. 
He  then  began  to  draw  deep  breaths  at  long  intervals  but  in  two  or  three 
minutes  the  pulse  and  respiration  both  stopped  and  the  patient  died. 


PROBLEMS  IN  DIAGNOSIS 

The  three  following  cases,  Autopsies  Nos.  2,  11,  and  26, 
illustrate  either  errors  of  diagnosis  or  interesting  complications 
of  typhus  fever. 

Autopsy  Number  2. 

Patient  of  Dr. . 

Clinical  Diagnosis:  Typhus  fever. 

Pathological  Diagnosis:  Malignant  endocarditis. 

Autopsy  Number  11. 

Patient  of  Dr. . 

Clinical  Diagnosis:  Typhus  fever. 

Pathological  Diagnosis:  Typhoid  fever  with  perforation  of  the 
intestine. 
Autopsy  Number  26. 
Patient  of  Dr.  Smith. 
Clinical  Diagnosis:  Typhus  fever  (?)'. 
Pathological  Diagnosis:  Endocarditis,  typhus  fever  (?). 

Clinical  Notes 

The  patient  was  admitted  June  14.  His  age  was  30  and  he  is  said  to  have 
been  ill  four  days.  No  eruption  was  seen  on  admission  or  later.  The  patient 
was  conscious  at  first  and  became  comatose  later.  The  breathing  was  noisy 
and  difficult.  There  was  muscular  twitching.  The  general  appearance  of 
this  patient  suggested  typhus  fever.  On  June  22  the  neck  was  markedly 
stiff  and  there  was  a  slight  Kernig's  sign.  The  patient  died  at  3.40  p.m. 

Autopsy  Findings 

Postmortem  performed  five  hours  after  death.  Body  fairly  well  nour- 
ished. 

Heart:  There  is  a  large  milk-patch  on  the  anterior  surface.  The  left 
ventricle  is  firmly  contracted,  and  there  is  no  dilatation  of  any  of  the  cham- 
bers. The  mitral  valve  shows  a  continuous  row  of  small,  pearly  white,  soft 
vegetations  along  the  edge.  Beneath  the  endocardium  a  little  above  one  of 
the  cusps  is  a  small  area  of  haemorrhage.  There  is  no  ulceration.  The  other 
valves  are  natural.  The  intima  of  the  aorta  shows  a  few  very  small  yel- 
lowish patches.  The  coronary  openings  are  free. 

235 


236  PROBLEMS  IN  DIAGNOSIS 

Lungs:  The  left  shows  much  oedema,  especially  at  the  base.  The  base  of 
the  right  is  oedematous  and  atelectatic. 

Abdomen:  The  intestines  are  normal  in  appearance.  The  lower  part  of 
the  ileum  was  opened  and  no  ulceration  or  swelling  was  found  but  the 
mucous  membrane  showed  many  minute  red  dots. 

Li2;er;  Much  congested, 

ASpZeew;  Normal  in  size,  rather  firm.  ; 

Kidneys:  Extremely  congested.  ♦ 

Brain:  Shows  whitish  streaks  along  some  of  the  larger  arteries  on  the 
upper  and  lateral  surfaces  of  the  hemispheres.  No  pus  on  the  meninges. 
Cranial  fluid  perhaps  a  little  in  excess.  Meninges  not  oedematous.  Base  of 
brain  natural.  Lateral  ventricles  contain  a  pale  and  slightly  turbid  fluid. 
Lumbar  puncture  after  death  showed  that  the  fluid  was  not  under  tension. 
Several  cubic  centimeters  were  removed  with  a  syringe.  The  fluid  was  clear 
and  greenish  yellow  in  color.  ' 

Series  Number  33. 

Diagnosis:  Scabies,  typhus  iever  (7). 

Clinical  Notes        ■ 

May  8.  Serbian,  apparent  age  about  20.  The  patient  says  he  has  had 
typhus  for  a  month  which  probably  means,  that  he  has  had  scabies  for  a 
month. 

Physical  Examination:  The  patient  is  well  developed  and  nourished. 
The  skin  and  mucous  membranes  are  pale.  The  conjunctivae  are  slightly 
injected. 

The  skin  of  the  body  and  face  is  somewhat  pigmented  and  shows  many 
brown  macules  of  various  sizes.  There  are  many  excoriated  papules  upon 
the  front  of  the  chest,  abdomen,  upper  arms^  axillae,  groins,  wrists^  and 
genitals.  There  are  no  such  papules  below  the  knees.  The  forearms,  wrists, 
and  hands  show  many  crusted  papules  of  moderate  size  and  there  are^ 
similar  ones  on  the  lower  legs. 

On  the  chest  there  are  &Jew  pink  macwZes  which  might  be  interpreted  as 
a  scanty  eruption  in  a  mild  case  of  typhus. 

The  other  lesions,  clearly,  are  due  to  scabies. 

Heart  and  Lungs:  Negative, 

Abdomen:  Soft,  not  tender.  Spleen  not  palpable;  splenic  dulness  not 
increased.  i, 

Knee-jerks  present.  No  stiffness  of  neck  or  legs. 

Haemoglobin  (Tallquist),  100  per  cent  +.  Blood-pressure,  105/S.- 
65/D.    _  ■  '[    '     '       '^       "  .""  '.       , 

May  13.   Throat  slightly  red.   Heart,  lungs,  and  abdomen  negative. 


PROBLEMS  IN  DIAGNOSIS 


237 


May  14.  Skin  improving  under  treatment  for  scabies.  Few  brown  spots 
remain. 

Junel.  Patient  discharged  well. 

Note  :  The  temperature  curve  in  this  case  points  to  an  acute  infection 
of  some  sort  and  the  small  amount  of  local  infection  of  the  skin  lesions  can- 

CUNICAL  CHART 

NAME._Se.rie  S  *33 ward bed  no date   May  8,  1315. 

MEDICAL  RECORD   BOOK.  VOL. ..  PASE DISEASE.Sc.Q.bl  fi-S  ...'>t-Ty  ph  LI  S    feVCl-? 


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not  explain  it.  Although  more  irregular  than  the  curve  usually  is  in  typhus 
the  chart  suggests  this  disease  and  the  pink  macules  above  mentioned 
strengthen  such  an  hypothesis. 


Series  Number  33a. 

Diagnosis:  Gangrene  of  foot  and  leg,  probably  a  sequel  of 
typhus  fever. 


238  PROBLEMS  IN  DIAGNOSIS 

Clinical  Notes 

April  26.  A  Serbian.  Brought  in  with  a  number  of  typhus  patients  that 
arrived  together  on  a  train.   Said  that  he  had  been  ill  eight  days. 

Spots  were  seen  which  may  have  been  a  fading  typhus  rash,  but  which 
were  not  sufficiently  definite  for  a  positive  diagnosis. 

At  the  time  of  admission  there  was  pronounced  discoloration  of  the  left 
foot  and  of  the  leg  halfway  to  the  knee,  a  line  of  demarcation  existed  at  the 
"point  of  election." 

May  5.  The  patient  was  transferred  to  a  surgical  hospital  for  amputa- 
tion of  the  leg. 

Note  :  This  case  illustrates  the  difficulty  of  satisfactory  diagnosis  after 
the  eruption  has  faded . 

Series  Number  88. 

Diagnosis:  Pappataci  fever  (?).   Abortive  typhus  (??). 

Clinical  Notes 

May  26.  The  patient  has  been  sick  two  days.  He  complains  of  pain  in 
the  temples,  thighs,  and  back. 

Physical  Examination:  The  patient  is  rather  drowsy,  but  mentally  clear 
and  alert  when  aroused.  The  pupils  are  equal  and  of  moderate  size.  The 
conjunctivae  are  moderately  injected.  The  tongue  shows  a  thin,  white 
coat.  The  throat,  the  soft  palate,  the  pillars  of  the  fauces,  and  the  pharynx 
are  red.  There  are  no  spots  on  the  mucous  membranes. 

The  Heart  is  negative,  the  pulse  of  good  quality,  and  the  blood-pressure, 
90/S.-60/D.    Haemoglobin,  80  per  cent. 

The  Lungs  and  Abdomen  are  negative.  The  splenic  dulness  is  not  in- 
creased and  the  spleen  is  not  palpable. 

The  knee-jerks  are  present.  There  is  no  stiffness  of  the  neck  or  legs.  The 
thigh  muscles  are  slightly  sensitive  to  firm  pressure. 

Skin:  The  face  is  covered  with  a  red  flush  which  extends  two-thirds  of 
the  way  down  the  neck  and,  in  front,  covers  a  V-shaped  area  extending  on  to 
the  sternum.  A  slighter  flush  extends  over  the  lower  part  of  the  neck  to  the 
shoulders  and  over  the  clavicles  to  the  second  ribs  where  it  gives  place  to 
rose-colored  macules.  The  ears  are  very  red.  On  the  sides  of  the  chest,  the 
flanks,  and  the  abdomen  there  are  a  few  bright  red,  clearly  defined  spots  the 
size  of  a  pinhead  and  a  few  purplish  spots  of  about  the  same  size  which  do 
not  disappear  on  pressure.     (Old  flea  bites?) 

On  the  inner  aspects  of  the  arms  and  of  the  flanks  "  taches  bleuatres  "  are 
numerous.  In  the  center  of  some  of  these  is  a  bright  red,  circumscribed  spot 
like  those  already  described  on  the  sides  of  the  chest  and  flanks.  These 
spots  are  believed  to  have  been  caused  by  bites. 


PROBLEMS  IN  DIAGNOSIS 


239 


On  the  hips  and  on  the  backs  of  the  hands  are  a  considerable  number  of 
maculopapules  some  of  which  are  capped  by  a  small  vesicle.  The  nature  of 
these  spots  is  uncertain.  They  resemble  acne  more  than  anything  else. 

June  2.  On  the  day  after  admission  of  the  patient  the  temperature 
dropped  to  normal.    On  the  same  day  a  rash  consisting  of  groups  of  very 

CUNICAL  CHART 

NAME. -  Sen e a  *  8 B date  I\ ay  x5, 1915. 

MEDICAL  RECORD  BOOK,  VOL. DISEASE ry.pku  S faveV. -. 


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Series  Number  88.      Pappataci 
fever  (?).    Abortive  typhus  (??) 


small,  irregular  papules  was  found  on  the  flanks  and  sides  in  the  morning. 
In  the  afternoon  it  had  nearly  disappeared  and  in  the  evening  there  was  no 
sign  of  it.  The  patient's  condition  today  is  excellent. 

June  11 .  With  the  exception  of  a  rise  of  temperature  to  99"  on  one  day, 
there  has  been  no  recurrence  of  fever.  The  patient  is  to  be  discharged 
tomorrow. 

Note  :  The  probability  in  this  case  seems  in  favor  of  the  diagnosis  of 
pappataci  fever. 


240 


PROBLEMS  IN  DIAGNOSIS 


Series  Number  100. 

Diagnosis:  Pneumococcus  bronchitis.   Typhus  fever  (??). 

Clinical  Notes 

June  21.  Admitted  to  hospital  today.  Duration  of  illness  ten  days. 
Physical  Examination:  The  face  is  flushed  and  the  conjunctivae  are  in- 
jected.  There  is  pink  mottling  of  the  skin  on  the  chest  and  abdomen  but 


CUNICAL  CHART 

NAME,  .Sen  eS  *  lOQ ..ward bed  no.. _oate  Jan e.-SJ.,  1915. 

MEDICAL  RECORD    BOOK,  VOU  «fc.PAG 


-  DisEASE.,_..Xy.pKu5 ^.cv.ey.. 


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Typhus  fever  (??) 

there  are  no  macules  or  papules.  The  tongue  shows  a  brown  coat.  The 
mind  is  cleair  and  the  general  condition  is  good.  The  spleen  is  not  palpable. 

June  24.  There  is  profuse  purulent  expectoration.  The  face  is  still  a- 
Uttle  flushed  and  a  band  of  injection  extends  across  the  conjunctivae. 

The  lungs  were  negative  yesterday  and  today.  .  .    ^ 


PROBLEMS  IN  DIAGNOSIS  241 

The  patient  is  improving  and  does  not  look  seriously  sick.  Micro- 
scopical examination  of  the  sputum  shows  pneumococci  in  great  numbers 
and  few  other  bacteria.   No  tubercle  bacilli  were  found. 

Note  :  The  most  probable  diagnosis  seems  to  be  bronchitis  caused  by  the 
pneumococcus.  The  ''mottling"  on  the  chest  may  have  been  due  to  the 
appHcation  of  a  counterirritant  of  some  sort. 

There  seems  no  reason  for  believing  the  case  to  be  one  of  typhus  fever 
although  the  patient  was  sent  in  as  such. 


PART  III 

LABORATORY  EXAMINATIONS  IN  TYPHUS 

FEVER 

By  ANDREW  WATSON  SELLARDS 

Intkoduction 

In  order  to  complete  the  arrangements  of  the  commission  for 
conducting  sanitary  work,  a  central  laboratory  was  organized 
by  Dr.  Hans  Zinsser  in  Skoplje  at  the  Lady  Paget  Hospital. 
The  scope  of  this  laboratory  included  the  preparation  of  various 
vaccines,  the  sanitary  examination  of  water  supplies,  and  more 
particularly,  special  investigations  of  typhus  fever.  The  op- 
portunity was  afforded  me  to  carry  out  clinical  laboratory 
examinations  on  typhus  fever  patients. 

The  general  findings  in  typhus  fever  were  observed  with  the 
special  object  of  differentiating  this  disease  from  other  infec- 
tions which  were  prevalent  and  in  which  an  early  clinical  di- 
agnosis could  not  be  made.  Of  the  acute  infections  which  gave 
rise  to  confusion,  the  two  most  troublesome  ones  were  typhoid 
and  relapsing  fever.  Indeed  the  clinical  similarity  in  the  onset 
of  these  three  diseases  gave  rise  to  a  local  custom  in  the  Balkan 
States  of  designating  them  all  by  the  one  name  "typhus."  It 
was  often  only  by  the  context  that  one  could  determine 
whether  reference  was  made  to  typhus  exanthematicus,  typhus 
recurrens,  or  typhus  abdominalis.  The  rapid  clinical  differen- 
tiation of  typhus  and  relapsing  fever  would  have  been  advan- 
tageous since,  in  the  management  of  the  sanitary  work,  it  had 
seemed  desirable  to  the  authorities  to  reserve  the  Lady  Paget 
Hospital  solely  for  typhus  cases.  Once  the  cases  had  been  ad- 
mitted, the  prompt  diagnosis  was  important  to  prevent,  as  far 
as  possible,  the  development  of  cross  infections  in  the  hospitals. 

243  .... 


244      EXAMINATION  OF  THE  BLOOD  IN  TYPHUS  FEVER 

Examination  of  the  Blood  in  Typhus  Fever 

In  the  literature  on  the  cHnical  microscopy  of  the  blood  in  ty- 
phus fever  certain  important  statements  occur  which,  for  the 
most  part,  have  remained  unconfirmed.  Even  as  regards  the 
actual  blood  counts,  and  the  morphology  of  the  blood-cells, 
the  statements  are  somewhat  conflicting.  In  searching  for  para- 
sites, Ricketts  and  Wilder  ^  in  a  preliminary  note  reported  the 
finding  of  bacteria  in  blood  films  stained  by  Giemsa's  method; 
with  similar  preparations  Prowazek  ^  noted  the  occurrence  in 
the  white  cells  of  inclusion  bodies  of  the  general  character  of  the 
chlamydozoa. 

Red  Blood-Cells 

Prompt  confirmation  was  obtained  of  the  high  count  of  red 
blood-cells,  figures  of  5,500,000  and  6,000,000  being  common, 
the  haemoglobin  content  being  increased  often  in  greater  pro- 
portion than  could  be  accounted  for  by  the  increase  in  the 
number  of  red  cells.  The  percentage  of  haemoglobin  was  de- 
termined with  a  Sahli  apparatus  standardizing  the  instrument 
by  comparing  it  with  several  normal  healthy  adults  and  con- 
sidering this  value  as  100  per  cent.  The  blood  examined  was 
taken  in  all  cases  from  the  ear.  This  increase  in  cell  count  and 
haemoglobin  was  most  marked  at  the  height  of  the  infection. 
With  the  progress  of  the  disease,  the  count  usually  fell  to  nor- 
mal or  even  to  slightly  subnormal  values;  a  definite  anaemia  did 
not  develop  in  typical  cases.  Some  of  the  conditions  bearing  on 
this  increased  count  were  considered.  Clinically,  there  was  no 
increase  in  the  size  of  the  spleen  in  contrast  to  the  spleno- 
megaly which  sometimes  accompanies  polycythaemia.  Many 
of  these  patients  showed  the  effects  of  depletion  in  their  supply 
of  fluids.  The  explanation  of  this  lay  not  in  an  excessive  loss  of 
fluid  due  to  any  effect  of  the  typhus  infection,  but  to  the  in- 
ability of  the  patients  to  obtain  water  during  their  long  journey 
to  the  hospital.    In  order  to  determine  in  how  far  the  poly- 

1  Ricketts  and  Wilder:  Jour.  Am.  Med.  Assn.,  1910,  liv,  1373. 

2  Prowazek:  Med.  Rec,  N.  Y.,  1915,  Ixxxviii,  21;  Beitr.  z.  Klinik  d.  Infections,  u.  z. 
Immunitatsforsch.,  iv,  No.  1. 


TYPHUS  IN  SERBIA  245 

cythaemia  was  due  to  deprivation  of  water,  a  series  of  counts 
was  made  upon  selected  cases  in  whom  the  therapeutic  injec- 
tion of  salt  solution  was  required.  These  injections  were  made 
intravenously,  in  quantities  of  one-half  to  three-fourths  of  a 
liter.  The  first  injection  often  showed  surprisingly  little  effect 
upon  the  blood-count;  repeated  injections  usually  reduced  the 
red  count  and  the  haemoglobin  considerably.  The  values  often 
remained  slightly  higher  than  normal  even  after  sufficient 
fluid  had  been  injected  to  restore  the  tissues  approximately  to 
their  normal  condition.  Signs  of  this  restoration  consisted 
chiefly  in  the  return  of  the  elasticity  of  the  skin,  the  improve- 
ment of  the  pulse,  and  the  free  secretion  of  urine.  It  seemed 
justifiable  to  conclude  that  the  deprivation  of  water  was  re- 
sponsible in  a  large  measure  for  the  high  red  counts  and  high 
haemoglobin,  though  one  could  not  exclude  the  possibihty  that 
other  factors  may  play  a  minor  role. 

In  fresh  preparations  and  in  stained  smears  the  red  cells  were 
essentially  ^  normal.  In  a  small  proportion  of  the  cases  the  red 
cells  showed  coarse  basophihc  stippling  and  occasionally 
polychromatophilia.  This  feature  occurred  indifferently  both 
in  the  cases  with  moderately  low  counts  and  also  in  some  in- 
stances in  which  the  red  cell  count  was  as  high  as  6,000,000. 

White  Blood-Cells 

In  regard  to  the  white  blood-cells  there  is  a  prevalent  opinion 
that  a  leucocytosis  of  high  grade  often  occurs  late  in  the  dis- 
ease, characteristic  large  mononuclear  cells  appearing  in  the 
blood.  The  total  number  of  white  cells  was  found  to  be  rather 
variable.  Often  the  count  was  normal  or  a  little  high.  In  a  few 
instances  a  marked  leucopoenia  was  present.  These  leuco- 
poenias,  however,  were  rather  transient  instead  of  persisting 
over  a  period  of  days  or  weeks  as  in  typhoid  fever.  Occasionally 
a  striking  leucocytosis  developed  during  the  second  week  of  the 
disease.    Thorough  examination  often  revealed  some  focus  of 

1  The  Giemsa  stain  was  used  exclusively,  partly  because  this  stain  kefeps  very  well  in 
warm  climates  and  also  because  the  work  of  Ricketts  and  Prowazek  is  based  upon 
smears  stained  with  Giemsa's  method. 


246   EXAMINATION  OF  THE  BLOOD  IN  TYPHUS  FEVER 

secondary  infection.  Two  patients  with  high  counts  in  whom 
no  compHcations  could  be  found  developed,  after  a  few  days,  a 
small  patch  of  pneumonia.  A  few  cases  developed  leuco- 
cytosis,  however,  in  which  no  suggestion  of  secondary  infection 
could  be  detected. 

The  differential  counts  showed  considerable  variation.  Fre- 
quently the  mononuclear  cells  were  increased  at  the  expense  of 
the  polymorphonuclears  and  often  the  large  non-granular 
mononuclear  cells  were  unusually  prominent.  These  cells  were 
often  difficult  to  classify.  Polymorphonuclear  cells  that  ap- 
peared to  be  rather  young  were  seen  not  infrequently.  An 
occasional  neutrophilic  myelocyte  was  seen  in  the  peripheral 
blood.  These  were  rare  being  by  no  means  as  frequent  as  in 
some  of  the  high  grade  bacterial  leucocytoses. 

A  thorough  examination  of  the  blood  in  ten  active  cases  of 
the  disease  failed  to  reveal  either  the  bacilli  described  by 
Ricketts  or  the  inclusion  bodies  of  Prowazek.  Most  of  these 
patients  were  examined  for  the  first  time  at  about  the  fourth  or 
fifth  day  of  the  disease  and  subsequently  throughout  the  re- 
mainder of  the  course  at  intervals  of  two  or  three  days. 

The  platelets  were  abundant  in  the  blood  smears  and  they 
were  normal  in  appearance.  The  bleeding  time  and  the  coagu- 
lation time  were  within  normal  limits.  The  latter  was  deter- 
mined by  drawing  the  blood  in  a  syringe  from  a  vein  and 
noting  the  time  required  for  coagulation  in  a  test  tube. 

It  is  not  infrequently  stated  that  the  blood  of  typhus  cases  is 
very  prone  to  give  the  reactions  of  agglutination  and  comple- 
ment fixation  with  various  antigens.  Cameron  ^  has  empha- 
sized the  occurrence  of  positive  Widal  reactions  with  the  sera 
of  typhus  patients.  In  view  of  his  observations,  some  macro- 
scopic agglutination  tests  were  carried  out  in  the  Lady  Paget 
Hospital  using  B.  typhosus  and  the  two  paratyphoid  strains,  A 
and  B.  Twenty  typhus-  cases  were  examined  three  of  which 
were  active  and  the  others  were  convalescent.  No  positive  re- 
actions were  obtained  with  either  of  the  two  strains  of  para- 
typhoid.  With  the  typhoid  strain  there  were  five  cases  which 

1  Cameron:  Brit.  Med.  Jour.,  1915,  i,  785., 


TYPHUS  IN  SERBIA 


247 


TABLE    I. —BLOOD    COUNTS    AND    HAEMOGLOBIN    DETERMINATIONS 
ON  TYPHUS  CASES  UPON  ADMISSION 


Case  no. 

Day  of  disease 

Red  cell  counts 
Millions  per  c.mm. 

White  blood-cells 
Number  per  c.mm. 

Haemoglobin 

Sahli 

1 

4 

4,0 

12,000 

120 

3 

8 

6,0 

6,000 

135 

8 

10? 

5,6 

5,000 

95 

9 

8 

5,5 

4,600 

125 

10 

8 

5,9 

16,600 

130 

11 

5 

4,0 

6,000 

90 

15 

14* 

4,0 

7,200 

100 

16 

18* 

4,1 

3,200 

110 

17 

14* 

5,6 

6,000 

120 

18 

5 

4,7 

1,500 

95 

19 

5 

4,4 

8,800 

105 

20 

16* 

3,9 

4,800 

85 

21 

6 

3,5 

3,900 

110 

35 

5 

4,5 

7,600 

110 

41 

6 

4,7 

3,700 

110 

45 

8? 

5,0 

4,000 

115 

46 

2 

5,1 

10,600 

115 

47 

7 

4,9 

4,800 

115 

53 

? 

5,6 

4,300 

130 

55 

4 

6,2 

5,800 

145 

56 

6 

5,2 

10,200 

115 

57 

12 

4,6 

7,800 

110 

58 

10 

5,0 

15,000 

115 

*  These  are  patients  who  reported  themselves  ill  from  some  unknown  cause  and  in 
whom  typhus  fever  developed  as  an  intercurrent  infection. 

gave  good  agglutination  at  a  dilution  of  1 :  25,  but  not  at  1 :  50. 
In  the  entire  series  there  was  but  one  case  which  gave  agglu- 
tination at  1 :  50  and  the  clinical  diagnosis  of  typhoid  fever  had 
already  been  made  in  this  patient.  In  the  cases  agglutinating 
at  1 :  25  no  record  was  available  in  regard  to  their  previous 
history  of  typhoid  fever  and  of  antityphoid  vaccination;  con- 
sequently, even  if  an  occasional  positive  Widal  had  been  ob- 
tained in  the  typhus  cases  it  would  not  have  been  of  any 
especial  significance. 

For  completeness  sake  some  of  the  data  of  the  blood  counts 
are  appended.  The  data  in  regard  to  the  time  of  onset  of  the 
disease  are  extremely  unsatisfactory.   Many  patients  were  too 


248      EXAMINATION  OF  THE  BLOOD  IN  TYPHUS  FEVER 

ill  to  give  a  reliable  history;  others  did  not  consider  themselves 
ill  unless  a  rash  or  high  fever  developed.  The  data  for  the  ''  day 
of  the  disease"  as  given  in  Table  I  are  compiled  in  part  from 
the  history  of  the  patient  and  in  some  cases  from  the  apparent 
stage  of  the  disease  as  judged  by  the  clinical  findings. 

In  ten  additional  cases  occurring  toward  the  close  of  the 
epidemic  and  showing  no  complications,  the  white  count  dur- 
ing the  first  week  of  the  disease  varied  from  3800  to  13,000. 

In  Table  II  some  typical  differential  counts  are  recorded. 


TABLE 

II.  —  DIFFERENTIAL  COUNTS 

ON  TYPHUS  CASES 

Day  of 

Total 

Polymor- 
phonuc- 

Large and 

Large 

Transi- 
tional 

Unclassi- 

Eosinophiles 

disease 

count 

lear  neut- 
rophiles 

phocytes 

nuclears 

cells 

fied  cells 

Number  seen 

1 

4 

12,000 

92% 

3% 

4% 

0% 

1% 

None 

3 

8 

6,000 

77 

13 

10 

0 

0 

One  cell 

8 

10? 

5,000 

72 

18 

6 

2 

2 

Two  cells 

9 

8 

4,600 

82 

8 

6 

0 

4 

None 

10 

8 

16,600 

72 

17 

8 

2 

1 

One  cell 

11 

5 

6,000 

72 

20 

6 

1 

1 

None 

17 

? 

6,000 

72 

20 

4 

2 

2 

18 

5 

1,500 

47 

31 

15 

3 

3 

None 

19 

5 

8,800 

73 

17 

2 

5 

3 

None 

20 

? 

4,800 

76 

18 

2 

2 

2 

Two  cells 

21 

6 

3,900 

70 

18 

6 

3 

3 

None 

87 

4 

12,000 

76 

21 

2 

1 

0 

None 

These  percentages  are  based  upon  counts  of  300  cells. 

The  eosinophiles  were  unexpectedly  scarce,  never  being  as  high  as  one  per  cent. 

An  attempt  was  made  to  follow  the  blood-counts  from  the 
onset  of  the  disease  throughout  its  course  in  a  small  group  of 
uncomplicated  cases.  The  effort  to  secure  such  a  series  was  not 
very  successful.  In  Table  III,  although  the  exact  day  of  the  on- 
set is  not  accurately  known,  still  the  figures  give  a  very  fair 
idea  of  the  stage  of  the  disease.  These  counts  were  made  from 
uncomplicated  cases  or  at  least  the  patients  were  free  from 
complications  at  the  time  these  observations  were  made.  As 
regards  the  effect  of  complications  there  seemed  to  be  a  com- 
paratively large  proportion  of  cases  in  which  pyogenic  ab- 
scesses failed  to  produce  a  polymorphonuclear  leucocytosis. 


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TYPHUS  IN  SERBIA      "  249 

Examination  of  the  Urine 

Examination  of  the  urine  showed  an  almost  constant  and 
early  development  of  some  inflammation  of  the  kidney.  Mod- 
erate amounts  of  albumin  were  present  and  granular  casts  were 
fairly  numerous.  These  signs  were  usually  transient,  clearing  up 
promptly  with  the  drop  in  temperature.  In  one  instance  only, 
a  severe  nephritis  developed  during  the  height  of  the  disease 
which  did  not  entirely  clear  up  during  convalescence;  in  this 
case  a  preexisting  nephritis  could  not  be  excluded. 

The  diazo-reaction  was  found  to  be  almost  constantly  pres- 
ent and  usually  very  strong.  However,  it  did  not  occur  early 
in  the  disease  and  it  was  not  of  definite  value  in  the  differentia- 
tion of  early  or  doubtful  cases. 

Differential  Diagnosis 

We  do  not  at  present  possess  routine  methods  which  are  ade- 
quate for  the  recognition  of  atypical  cases  of  typhus  fever  or  for 
the  early  diagnosis  before  the  typical  clinical  picture  has  de- 
veloped. Among  the  French  physicians  a  high  percentage  of 
cases  are  frequently  diagnosed  as  typhus  "sin  exanthem"; 
while  this  type  may  occur  more  or  less  frequently,  it  is  a  di- 
agnosis which  is  extremely  difficult  to  establish.  The  more 
common  laboratory  procedures  give  evidence  in  typhus  which 
is  essentially  negative  in  character.  Of  the  few  positive  find- 
ings, the  occurrence  of  the  diazo-reaction  in  the  urine  and  the 
tendency  of  the  mononuclear  cells  of  the  blood  to  increase  were 
.of  only  very  minor  assistance.  The  diagnosis  of  typhus  by  the 
laboratory  findings  must  be  made  by  exclusion.  This  is  fre- 
quently unsatisfactory  for  its  differentiation  both  from  typhoid 
and  from  relapsing  fever. 

The  application  to  typhus  fever  of  some  of  the  mOre  elabo- 
rate experimental  procedures  gives  results  which  are  char- 
acteristic. The  inoculation  of  the  virus  of  typhus  fever  into 
monkeys  and  guinea  pigs  often  gives  rise  to  a  characteristic 
temperature  curve;  studies  of  complement  fixation  and  agglu- 
tination to  B.  typhi  exanthematici  have  in  the  hands  of  Plotz, 


250         CULTURES  IN  TYPHUS  FEVER 

Olitsky,  and  Baehr  ^  given  results  of  diagnostic  value.  The 
transmission  of  the  virus  to  lower  animals  is  at  present  out 
of  consideration  as  a  diagnostic  method;  the  results  are  so 
inconstant  that  the  procedure  is  suitable  only  for  the  labora- 
tory study  of  typhus.  Jahlous  ^  reports  that  there  is  a  general 
tendency  of  the  serum  of  typhus  cases  to  give  non-specific  com- 
plement fixation  with  the  Wassermann  antigens.  This  possi- 
bility in  typhus  fever  should  be  taken  into  consideration  in  any 
diagnostic  methods  involving  complement  fixation.  Olitsky  ^ 
finds  that  an  antigen  of  B.  typhi  exanthematici  fixes  comple- 
ment readily  with  the  sera  of  typhus  cases  but  not  with  other 
sera.  Furthermore,  antigens  prepared  from  other  bacilli  fail  to 
fix  complement  with  typhus  sera.  Olitsky's  results  though  very 
striking  have  not  yet  received  any  wide  confirmation.  The 
final  establishment  of  diagnostic  aids  by  the  use  of  comple- 
ment fixation  either  with  a  specific  or  a  non-specific  antigen 
requires  an  enormous  amount  of  empirical  work  carried  out 
preferably  in  a  number  of  different  laboratories. 

Bacteriological  Cultures  in  Typhus  Fever 

In  the  search  for  the  specific  organism  of  typhus  fever,  the 
blood  is  the  most  suitable  material  for  examination.  Injection 
of  blood  from  typhus  patients  into  normal  men  reproduces  the 
disease,  thereby  demonstrating  that  the  virus  occurs  in  the 
circulating  blood.  Numerous  bacteriological  cultures  have 
proven  that  the  virus  as  it  occurs  in  the  blood  is  practically 
pure. 

Of  the  many  organisms  that  have  been  described  as  the 
specific  aetiologic  factor  in  typhus  fever  there  is  none  on  which 
so  much  work  has  been  done  or  for  which  so  much  favorable 
evidence  has  been  offered  as  in  the  case  of  the  anaerobic  bacil- 
lus described  by  Plotz  and  his  associates.  The  following  at- 
tempts at  the  confirmation  of  this  organism  were  made  in 
Belgrade  and  its  vicinity.    The  technique  described  by  Plotz 

1  Plotz,  Olitsky,  and  Baehr:  Jour.  Infect.  Dis.,  1915,  xvii,  1. 

2  Jahlous:  Jour.  Med.  Research,  1914,  xxx,  131;  Delta,  Centfalbl,  f.  Bakteriol., 
I,  Abt.,  Orig.   1915,  Bd.  Ixxvi,  50. 


TYPHUS  IN  SERBIA  251 

was  followed  carefully  but  in  view  of  the  proportionately 
large  number  of  negative  results  obtained  by  Dr.  Zinsser  in 
Skoplje  some  additional  cultures  were  made  with  certain  minor 
modifications  of  the  Plotz  technique.  These  consisted  in  an  en- 
richment of  the  medium  and  an  increase  in  the  degree  of  anaero- 
biosis.  Three  samples  of  ascitic  fluid  were  used.  They  were 
free  from  bile  and  the  specific  gravity  varied  from  1.015  to 
1.018,  but  in  view  of  the  possibility  that  they  might  not  be  en- 
tirely suitable  for  the  growth  of  the  Plotz  bacillus  pieces  of 
kidney  tissue  were  added  in  some  instances.  This  procedure 
had  given  successful  results  in  Plotz 's  experience  but  was  re- 
garded by  him  as  an  unnecessary  refinement.  Some  of  the 
Plotz  cultures  to  which  kidriey  tissue  had  been  added  were 
given  a  higher  degree  of  anaerobiosis  by  placing  the  tubes  in  a 
jar  from  which  the  oxygen  had  been  absorbed  by  yellow 
phosphorus. 

In  the  selection  of  cases,  only  those  patients  were  chosen 
from  whom  cultures  could  be  made  some  time  during  the  first 
half  of  the  period  of  the  exanthem,  except  in  one  instance  when 
a  fulminating  case  was  cultured  who  died  eight  hours  later. 
The  cultures  from  this  patient  developed  numerous  colonies, 
some  cocci  growing  aerobically,  and  some  bacilli  growing  an- 
aerobically;  the  latter  were  longer  and  coarser  than  the  or- 
ganism described  by  Plotz.  Cultures  from  twelve  additional 
cases  remained  sterile  for  one  month  with  the  exception  of  an 
occasional  mould  or  coarse  coccus  growing  on  the  surfaces  of 
the  media  toward  the  end  of  this  period.  No  anaerobic  growth 
occurred  either  in  the  cultures  made  by  Plotz 's  technique  or  in 
those  tubes  to  which  kidney  tissue  was  added  some  of  which 
were  placed  in  an  anaerobic  jar.  Five  of  these  twelve  cases 
were  cultured  either  on  the  first  or  second  day  of  the  appear- 
ance of  the  rash.  Moreover,  the  work  was  done  under  very 
favorable  conditions.  The  laboratory  at  Belgrade  was  housed 
in  a  substantial  building  and  was  well  equipped  with  modern 
French  apparatus.  In  Serbian  Macedonia  it  had  been  neces- 
sary to  work  practically  under  field  conditions  with  a  labora- 
tory set  up  in  what  was  formerly  a  Turkish  artillery  shed,  where 


252         CULTURES  IN  TYPHUS  FEVER 

the  exposure  to  dust  storms  added  greatly  to  the  difficulty  of 
the  work. 

It  is  hard  to  understand  this  failure  to  obtain  the  Plotz 
bacillus  under  favorable  conditions  in  view  of  the  practically 
constant  recovery  of  the  organism  from  acute  cases  by  Plotz 
and  his  associates.  Although  it  is  exceedingly  treacherous  to 
work  with  unheated  and  unsterilized  media,  yet  in  a  large 
series  of  control  blood  cultures  Plotz  failed  to  obtain  this  or- 
ganism in  a  single  instance.  It  is  evidently  a  highly  parasitic 
organism  but  I  am  not  yet  convinced  that  it  occurs  only  in 
typhus  fever  or  that  it  is  pathogenic  for  man.  Although 
Plotz  has  collected  a  large  amount  of  evidence  in  favor  of 
this  organism,  there  are  still  some  serious  objections  to  its 
acceptance. 

Anderson  has  pointed  out  that  the  cultures  on  injection  into 
animals  give  rise  to  a  transient  fever  which  does  not  especially 
resemble  the  temperature  curve  of  typhus  fever;  moreover 
these  animals  on  subsequent  injection  with  typhus  fever  virus 
may  react  with  a  typical  rise  in  temperature.  If  a  liberal  dose 
of  the  living  organism  fails  to  protect  an  animal  against  typhus 
virus,  some  doubt  is  raised  as  to  whether  the  usual  small  vac- 
cinating dose  would  give  efficient  protection  in  man. 

In  addition  to  the  failure  to  obtain  the  anaerobic  bacillus 
isolated  by  Plotz,  I  was  likewise  unable  to  confirm  the  work  of 
Topley.^  In  kidney  tissue  ascitic  fluid  agar,  Topley  reports  the 
clouding  of  the  media  due  to  the  growth  of  minute  cocci  or 
bacilli.  On  this  medium,  cultures  of  a  diplococcal  organism 
were  obtained  in  each  of  eight  cases. 

As  regards  the  bacteriological  examination  of  the  urine  no 
confirmation  could  be  obtained  of  the  smaU  coccobacillus  re- 
ported by  Hort  and  Ingram.^ 

Specific  biologic  reactions  such  as  agglutination  and  com- 
plement fixation  were  not  attempted  in  view  of  the  negative 
results  in  these  cultures  and  the  inabihty  to  secure  a  strain  of 
Plotz 's  organism  at  this  time. 

1  Topley:  Jour.  Roy.  Army  Med.  Corps,  1915,  xxv,  215. 

2  Hort  and  Ingram:  Brit.  Med.  Jour.,  1914,  ii,  15. 


TYPHUS  IN  SERBIA  .  253 

Animal  Experimentation 

The  reported  transmission  of  typhus  to  animals,  especially 
to  guinea  pigs,  has  given  rise  to  considerable  confusion.  The 
recognition  of  the  disease  depends  almost  wholly  on  the  tem- 
perature reaction.  The  highest  febrile  reaction  produced  by 
the  typhus  virus  is  usually  not  greater  than  the  maximal  nor- 
mal temperature  of  the  guinea  pig.  However,  after  a  definite 
incubation  period,  this  maximal  temperature  is  sustained 
s-teadily  over  a  period  of  several  days  without  remissions  such 
as  occur  in  normal  animals.  There  may  be  considerable  doubt 
about  the  specific  nature  of  the  rather  transitory  rises  in  tem- 
perature following  the  injection  of  the  virus  of  measles  and 
scarlet  fever  into  lower  animals.  However,  in  the  case  of  ty- 
phus fever  it  would  seem  that  guinea  pigs  are  definitely  suscep- 
tible and  permit  the  growth  and  multiplication  of  the  virus  for 
a  time.  However,  not  all  individuals  react.  Indeed,  there  is 
every  gradation  between  a  typical  febrile  curve  and  no  reac- 
tion. Since  the  normal  temperature  of  the  guinea  pig  varies 
considerably,  it  is  often  impossible  to  interpret  mild  reactions. 
Indeed,  some  of  the  important  statements  in  the  literature  are 
based  upon  the  interpretation  as  positive  of  reactions  which  in 
no  way  differ  from  normal  fluctuations  in  temperature. 

In  the  following  work,  the  animals  were  inoculated  from 
cases  of  typhus  during  the  first  or  second  day  after  the  appear- 
ance of  the  rash.  Guinea  pigs  were  injected  intraperitoneally 
with  3  to  5  c.c.  of  blood  from  several  typical  cases  but  the  reac- 
tions which  followed  were  not  satisfactory.  Moreover,  after  a 
period  of  incubation  subinoculation  from  the  first  guinea  pig  to 
a  second  one  was  likewise  unsuccessful.  A  reaction  in  guinea 
pigs  corresponding  to  those  described  by  French  and  American 
authors  was  obtained,  however,  by  passing  the  virus  first 
through  a  monkey  and  then  through  a  guinea  pig,  analogous 
to  the  method  for  securing  the  infection  of  rats  with  relapsing 
fever.  The  reaction  in  a  monkey  produced  by  an  injection  of 
blood  from  a  human  case  is  illustrated  in  the  accompanying 
chart,  together  with  the  chart  of  a  control  animal.   Blood  cul- 


254      EXAMINATION  OF  THE  BLOOD  IN  TYPHUS  FEVER 

tures  taken  from  this  monkey  on  the  second  day  of  the  fever 
were  negative. 

Such  a  shght  rise  of  temperature  over  a  short  period  of  time 
is,  in  a  single  instance,  without  significance.    The  evidence, 


1            TEMPERATURE,    CFAHRENHEITS  SCALE) 

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and  guinea  pigs  and  is  responsible  for  this  rise  in  temperature 
lies  in  the  fact  that  one  can  in  a  certain  proportion  of  cases 
duplicate  these  results;  moreover  the  monkeys  appear  dis- 
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reaction,  an  instance  was  observed  of  natural  immunity  in  the 
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TYPHUS  IN  SERBIA 


255 


and  of  indefinite  reactions  renders  the  procedure  extremely 
tedious  and  treacherous  as  a  laboratory  method.  It  is  con- 
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means  for  the  recognition  of  typhus  in  animals.  This  is  espe- 
cially necessary  in  view  of  the  great  importance  attached  to  the 
experiments  on  the  louse  transmission  of  typhus  in  the  lower 
animals. 


256  TRANSMISSION  OF  TYPHUS  FEVER 

Question  of  the  Mode  of  Transmission  op 
Typhus  Fever 

Some  of  the  cardinal  features  concerning  the  mode  of  trans- 
mission of  typhus  fever  are  still  undetermined.  In  the  case  of 
malaria  and  yellow  fever  it  is  not  only  proven  that  these  dis- 
eases are  commonly  transmitted  in  man  by  mosquitoes  but  it  is 
clearly  established  that  they  are  not  propagated  in  any  other 
manner.  This,  of  course,  is  an  extremely  fortunate  circum- 
stance in  the  management  of  these  two  diseases.  In  typhus 
fever  there  is  ground  to  believe  that  it  may  be  transmitted 
either  by  droplet  infection  or  by  the  louse.  The  evidence  re- 
gai-ding  louse  transmission  is  in  a  somewhat  confused  condi- 
tion. 

The  transmission  of  typhus  to  monkeys  by  the  human  body 
louse  has  been  investigated  by  three  groups  of  authors,  namely, 
Nicolle  and  his  associates,^  Ricketts  and  Wilder,^  and  Ander- 
son and  Goldberger.^  These  authors  have  all  arrived  at  the 
same  conclusion :  namely,  that  typhus  is  transmissible  to  the 
monkey  by  the  body  louse.  However,  it  is  very  striking  that 
the  data  and  the  fundamental  premises  of  the  various  authors 
frequently  vary  widely  and  even  conflict  seriously.  Thus  the 
results  on  which  one  group  of  authors  base  their  conclusions 
would  frequently  be  unacceptable  to  the  other  two.  Ricketts 
and  Wilder  considered  that  all  normal  monkeys  are  susceptible 
whereas  Anderson  and  Goldberger  frequently  found  natural 
immunity  in  monkeys.  Nicolle  found  that  monkeys  which 
were  bitten  by  lice  without  developing  fever  were  subse- 
quently susceptible  to  the  injection  of  virulent  blood,  whereas 
Ricketts  obtained  the  opposite  result.  Nicolle  as  well  as  An- 
derson and  Goldberger  determined  infection  in  the  monkey  by 
the  febrile  reaction  whereas  Ricketts  in  his  experiments  on 

1  Nicolle,  Comte,  and  Conseil:  Ann.  de  Flnst.  Pasteur,  1910,  xxiv,  261;  Nicolle  and 
Conseil:  ibid.,  1911,  xxv,  109;  Nicolle,  Blanc,  and  Conseil:  Compt.  rend.  Acad.  d.  sc, 
1914,  clix,  663. 

2  Ricketts  and  Wilder:  Jour.  Am.  Med.  Assn.,  1910,  liv,  1304;  ibid.,  Iv,  309;  Wilder: 
Jour.  Inf.  Dis.,  1911,  ix,  9. 

3  Anderson  and  Goldberger:  Bull.  Hyg.  Lab.,  U.  S.  P.  H.  S.,  1912,  No.  86. 


TYPHUS  IN  SERBIA 


257 


louse  transmission  did  not  obtain  a  sufficiently  definite  rise  in 
temperature  to  permit  of  a  positive  diagnosis;  reliance  was 
placed  primarily  on  the  appearance  of  malaise  and  on  the 
immunity  test.  NicoUe  in  contrast  to  the  other  authors  found 
that  monkeys  infected  by  the  bites  of  lice  showed  two  distinct 
febrile  periods.  The  accompanying  outHne  gives  a  summary 
of  the  results  of  these  authors. 


EXPERIMENTAL  TRANSMISSION  OF  TYPHUS  TO  MONKEYS  BY 
THE  BODY  LOUSE 


Feeding  experiments 

Injection  of  emulsions  of  lice 

Positive 

Negative 

Doubtful 

Positive 

Negative 

Doubtful 

By  Nicolle  and  His  Collaborators 

No.  of  experiments 

4a 

3* 

0 

4 

%<^ 

Anderson  and  Goldberger  ^ 

No.  of  experiments 

1« 

2 

I 

0 

4 

1 

RiCKETTS   AND   WiLDER 

No.  of  experibaents 

7/ 

3 

0 

■2 

1 

(o)  These  animals  are  regarded  as  positive  by  the  authors  on  account  of  their  tempera 
ture  reactions  but  three  of  the  four  might  more  critically  be  considered  doubtful  or 
negative. 

(6)  Two  of  these  three  negative  animals  were  bitten  by  lice  which  had  fed  on  typhus 
patients  only  four  days  previously. 

(c)  These  animals  were  injected  with  lice  which  had  their  infecting  feeding  two  to 
seven  days  previously. 

{d)  Anderson  and  Goldberger  obtained  positive  results  also  with  head  lice. 

(e)   The  temperature  reaction  in  this  animal  was  not  very  convincing. 

(/)  Typical  temperature  reactions  were  not  obtained  but  typhus  was  diagnosed  be- 
cause these  animals  appeared  ill. 

Some  evidence  is  also  available  in  regard  to  the  transmission  by 
the  louse  in  man.  Two  of  NicoUe's  laboratory  attendants  in 
Africa  were  accidentally  bitten  by  lice  that  had  fed  on  infected 


258  TRANSMISSION  OF  TYPHUS  FEVER 

monkeys.  These  attendants  did  not  develop  typhus  fever.  In 
another  instance  an  attendant  in  a  jail  in  Africa  transferred 
lice  from  a  typhus  patient  to  a  healthy  individual.  This  in- 
dividual developed  typhus  after  the  usual  incubation  period. 
While  this  patient  was  presumably  not  exposed  to  typhus  in 
any  other  way  the  conditions  were  not  under  control  and  no 
definite  conclusions  are  permissible. 

While  no  direct  experiments  on  man  have  been  undertaken, 
some  data  were  obtained  by  Sergent,  Foley,  and  Vialatte  ^  in 
the  course  of  some  work  on  relapsing  fever.  A  normal  man,  who 
was  bitten  by  lice  that  had  fed  upon  a  case  of  relapsing  fever, 
developed  as  a  consequence  typhus  fever.  A  second  individual 
injected  with  lice  that  had  fed  on  this  case  of  relapsing  fever 
and  a  third  man  injected  with  eggs  of  these  lice  also  developed 
typhus  fever.  Apparently  none  of  these  individuals  developed 
relapsing  fever,  although  the  lice  contained  large  numbers  of 
spirochaetes.  These  authors  conclude  that  the  case  of  relaps- 
ing fever  must  have  been  infected  also  with  typhus  fever  and 
that  the  latter  was  transmitted  by  the  bites  and  by  the  injec- 
tion of  the  lice. 

Although  there  is  considerable  confusion  in  the  data  of  the 
experimental  transmission  of  typhus  to  monkeys,  still  there  is 
good  reason  to  accept  the  idea  of  louse  transmission  of  the  dis- 
ease both  experimentally  in  animals  and  in  man  under  natural 
conditions.  Such  circumstantial  evidence  as  we  were  able  to 
obtain  in  Serbia  was  in  full  accord  with  the  theory  of  louse 
transmission.  Certainly  the  vast  majority  of  all  patients  had 
been  bitten  repeatedly  by  lice.  However,  with  the  approach  of 
hot  weather  the  incidence  of  typhus  and  of  relapsing  fever  ap- 
peared to  diminish  more  rapidly  than  the  disappearance  of 
lice. 

It  should  be  emphasized  that  the  establishment  of  louse 
transmission  does  not  militate  against  the  possibiHty  of  the 
disease  being  transmitted  by  other  methods  also.  Indeed  the 
possibility  of  droplet  infection  in  typhus  must  be  considered 

1  Sergent,  Foley,  and  Vialatte:  Compt.  rend.  Acad.  d.  sc,  1914,  clviii,  964. 


TYPHUS  IN  SERBIA  259 

seriously.  A  few  cases  of  typhus  developed  in  the  Lady  Paget 
Hospital  among  the  staff  under  circumstances  which  per- 
mitted careful  observation.  Some  of  these  cases  seemed  to  be 
directly  traceable  to  louse  infestation;  others  could  not  readily 
be  explained  on  this  basis.  This  was  especially  true  in  the  case 
of  a  nurse  who  protected  herself  carefully  against  insects  in  all 
of  her  hospital  work.  Toward  the  end  of  the  epidemic,  the 
ward  under  her  charge  had  been  free  from  active  cases  for 
about  ten  days  when  a  patient  extremely  ill  with  typhus  was 
admitted.  It  happened  that  this  case  had  developed  serious 
mouth,  throat,  and  lung  complications,  necessitating  frequent 
sponging  and  swabbing,  the  cleansing  process  often  provoking 
more  or  less  coughing.  It  is  significant  that  both  this  patient 
and  presumably  the  ward  itself  were  free  from  lice,  that  the 
nurse  also  wore  an  effective  louse-proof  suit,  that  at  no  time 
had  she  any  reason  to  suspect  louse  contamination,  but  that 
she  did  not  wear  the  gauze  masks  providing  for  protection 
against  droplet  infection.  No  further  typhus  cases  came  under 
the  care  of  this  nurse;  about  two  weeks  later  in  Belgrade,  while 
en  route  to  England,  in  surroundings  perfectly  free  from  ty- 
phus, she  developed  a  typical  attack  of  the  disease.  While 
none  of  those  instances  occurring  spontaneously  under  natural 
conditions  can  afford  any  exact  proof,  nevertheless  they  are 
sufficiently  striking  to  merit  consideration. 

The  members  of  the  Commission  working  in  the  hospital 
with  typhus  cases  adopted  precautions  both  against  insects 
and  against  droplet  infection,  although  some  authorities  advise 
against  the  employment  of  precautions  for  droplet  infection. 
The  precautions  taken  against  the  louse  were  twofold  in  their 
nature,  consisting  in  the  destruction,  as  far  as  possible,  of  the 
lice  and  the  wearing  of  the  louse-proof  uniforms.  In  the  first 
place,  the  entire  hospital  was  theoretically  free  from  lice,  all 
patients  being  carefully  cleansed  before  admission.  Practi- 
cally, it  was  impossible  to  keep  the  wards  absolutely  and  con- 
stantly free  from  lice  though  the  living  quarters  of  the  staff 
were  always  free  from  such  contamination.  Accordingly  the 
louse-proof  suits  were  worn  only  in  the  wards  and  were  then 


260  TRANSMISSION  OF  TYPHUS  FEVER 

left  in  a  changing  room  and  were  never  worn  in  the  staff  quar- 
ters. This  regime  necessitated  the  use  of  a  fresh  uniform  at 
each  visit  to  the  wards.  The  uniforms  for  each  day  were  col- 
lected and  exposed  overnight  to  chloroform  vapor  and  were 
then  ready  for  use  the  next  morning.  This  procedure  for  de- 
stroying Hce  was  suggested  by  Dr.  C.  T.  Brues  of  Harvard 
University  and  it  proved  to  be  very  simple  and  effective.  In 
addition  to  the  use  of  these  uniforms,  antiseptic  baths  were 
taken  at  the  end  of  each  day's  work. 

An  ordinary  surgeon's  mask  was  used  for  protection  against 
droplet  infection.  Essentially  no  other  precautions  were 
adopted. 

Boston,  Mass.,  Deqember,  1915. 


PART  IV 

REPORT  OF  BACTERIOLOGIST  OF  THE  AMERICAN 

RED  CROSS  SANITARY  COMMISSION 

TO  SERBIA 

By  HANS  ZINSSER 

The  bacteriological  supplies  were  shipped  on  March  19,  and 
the  writer-  left  with  the  main  party  of  ten  on  the  Ducca 
d'Ahruzzi,  on  April  3.  He  arrived  at  Uskub  (Skoplje)  on  the 
evening  of  May  1,  where  a  general  survey  of  the  contents  of 
the  hospitals  was  made.  After  consultation  with  Dr.  Strong  it 
was  decided  that  the  bacteriological  work  should  begin  at 
Skoplje,  since  there  seemed  to  be  a  greater  concentration  of 
typhus  material  here  than  in  other  places.  Accordingly,  about 
a  week  after  arrival  at  Skoplje  the  writer,  together  with  Doc- 
tors Shattuck  and  Sellards,  moved  out  to  the  Sixth  Reserve 
or  Lady  Paget  Hospital,  situated  on  the  heights  along  the  Var- 
dar,  about  two  kilometers  outside  of  the  town.  There  were  said 
to  be  at  that  time  a  few  more  than  400  cases  of  typhus  fever  at 
the  hospital.  There  was  a  very  small  room  which  the  British 
unit  were  using  as  a  laboratory,  equipped  only  for  the  simplest 
clinical  tests,  available  at  the  time,  but  such  as  it  was,  the  full 
courtesies  of  everything  at  hand  were  extended  by  the  British 
physicians.  The  writer  wishes  to  lay  stress  at  this  place  upon 
the  generosity  and  uniform  courtesy  with  which  the  officials  of 
the  Serbian  government  and  the  British  hospital  received  and 
treated  the  American  workers  at  Uskub  throughout  their  stay. 

Establishment  of  Laboratory 

The  first  task,  of  course,  was  the  establishment  of  a  bac- 
teriological laboratory  in  which  suitably  controlled  work  could 
be  done,  the  writer  conceiving  it  as  his  mission  not  only  to  work 

261 


262  REPORT  OF  BACTERIOLOGIST 

on  typhus,  but  to  attempt  the  estabhshment  of  a  laboratory  to 
which  the  general  bacteriological  and  sanitary  work  of  the 
Commission  could  be  referred.   Although  the  suppHes  shipped 
from  New  York  had  not  arrived,  and  did  not  arrive  at  Skoplje 
until  May  17,  the  interval  was  spent  in  becoming  famihar  with 
typhus  in  its  clinical  aspects,  the  preparation  of  a  laboratory 
space  and  autopsy  room,  and  the  performance  of  autopsies. 
By  the  courtesy  of  the  Serbian  government,  a  portion  of  the 
main  artillery  shed  next  to  the  Administration  Building  was 
placed  at  the  disposal  of  the  Commission  for  the  establishment 
of  a  laboratory.   A  partition  had  been  put  up  in  this  shed,  but 
otherwise  it  consisted  of  a  bare  cement  floor,  with  windows 
unsuitable  for  microscopic  work,  without  running  water,  with- 
out electricity,  and  without  gas.   The  labor  of  several  Austrian 
prisoners  and  of  a  local  carpenter  were  placed  at  the  disposal  of 
the  bacteriologist,  and  the  space  was  divided  into  a  smaller 
autopsy  room  and  a  main  laboratory  room.    Windows  were 
broken  through  the  walls,  another  door  was  broken  through, 
cement  sinks  were  put  in,  and  a  pipe  was  run  from  a  well,  in  the 
yard,  to  the  laboratory.    A  tin  tank  of  about  four  cubic  feet 
capacity  was  found  and  placed  on  the  partition  between  the 
autopsy  room  and  the  laboratory,  and  from  this,  pipes  were  run 
to  the  sinks.   When  the  supplies  arrived  it  was  found  that  the 
box  containing  thermometers,  syringes,  and  the  more  expensive 
smaller  apparatus  —  platinum  wire,  etc.  —  had  been  lost  in 
transit.    The  electrical  apparatus  taken  along,  as  well  as  that 
requiring  gas,  could  not,  of  course,  be  used.    Fortunately,  a 
petroleum  lamp  incubator  had  been  taken,  and  Primus  kero- 
sene stoves  were  bought.    The  British  laboratory  worker.  Dr. 
Dalyell,  permitted  the  transfer  of  all  her  available  apparatus  to 
this  laboratory,  joining  forces  with  the  American  laboratory. 
Without  this  aid  and  cooperation  the  work  of  the  Commission 
would  have  been  very  seriously  hampered,  because  of  the  fact 
that  so  much  of  the  apparatus  brought  was  not  suitable  for  the 
conditions  encountered.     Finally  the  apparatus  was  put  in 
place  and  the  laboratory  was  in  suitable  working  condition  by 
about  the  twenty-fifth  of  May. 


TYPHUS  IN  SERBIA  263 

During  the  period  preceding  this,  the  writer  thought  that 
although  not  all  the  criteria  for  properly  controlled  bacteriology 
could  be  fulfilled  under  the  circumstances,  it  would  be  better  to 
begin  work  with  what  was  available.  Fortunately,  by  the  fore- 
sight of  Doctors  Shattuck  and  Sellards,  some  extra  supplies  had 
been  taken  with  the  party  of  ten,  some  of  which  duplicated  the 
special  bacteriological  orders,  and  with  these,  together  with 
what  was  borrowed  from  the  British,  work  was  begun.  An 
Austrian  prisoner,  placed  at  the  disposal  of  the  bacteriologist, 
was  trained  as  a  laboratory  assistant,  was  taught  to  make 
agar,  broth,  sterilize,  etc.  Autopsies  were  done  on  most  of  the 
cases  of  typhus  that  died  during  this  time,  and  smear  studies 
were  made  from  the  spleen  and  organs. 

Bacteriological  Examinations 

Cultures  also  were  made,  from  the  spleen  and  heart's  blood 
and  other  organs,  but  one  or  two  of  these  only  were  of  any 
great  value,  since  most  of  the  cases  that  died  at  this  time, 
died  very  late  in  the  disease,  after  the  temperature  had  been 
normal  for  anjnA^^here  from  two  to  ten  or  twelve  days,  and 
secondary  invaders,  such  as  streptococci  and  Gram-negative 
bacilli,  were  often  found  in  these  cultures.  Blood  cultures  were 
made  at  this  time  on  many  of  the  living  patients,  although 
few  of  the  cases  were  in  the  early  stage  of  the  disease  when 
they  came  under  observation  at  the  hospital.  The  large 
majority  of  the  cases  that  came  in  were  well  along  in  the 
disease,  having  often  been  brought  in  from  considerable  dis- 
tances under  conditions  that  did  not  permit  speed  of  trans- 
portation. In  none  of  these  early  cultures  was  it  possible 
to  fulfill  the  criteria  laid  down  by  Plotz  for  the  cultivation 
of  his  organism.  Ascitic  fluid  was  hard  to  obtain,  since  at  this 
time  almost. all  the  patients  in  the  hospitals  were  either  typhus 
or  relapsing  fever,  and  small  specimens  of  chest  fluid  only 
could  be  obtained.  These  were  often  not  sterile,  and  in  no  case 
during  this  early  period  did  we  obtain  an  ascitic  fluid  of  1015 
specific  gravity  or  over,  which  could  be  used  in  the  unheated 
and  unfiltered  condition  as  required  for  the  Plotz  method. 


264  REPORT  OF  BACTERIOLOGIST 

During  this  period,  blood  culture  "5,"  taken  with  one  of  the 
specimens  of  chest  fluid,  which  showed  no  growth  in  the  con- 
trols, showed  in  a  high  tube  in  glucose  agar  a  colony  about  two 
inches  from  the  top,  not  gas-forming,  with  a  white  halo  about 
it  due  to  acid  formation,  which  on  fishing  showed  a  short  bacil- 
lus, slightly  diphtheroid  in  form,  morphologically  correspond- 
ing roughly  to  the  organism  of  Dr.  Plotz.  Comparing  smears 
from  an  old  culture  of  the  Plotz  bacillus  with  this  organism, 
great  similarity  was  seen,  except  that  our  organism  appeared  to 
be  very  slightly  larger  than  the  Plotz  organism  and  a  little  more 
irregular  in  form.  We  were  not  successful  in  carrying  this  cul- 
ture to  the  second  generation,  probably  because  we  were  at  that 
time  not  in  possession  of  suitable  ascitic  fluid.  We  wish  to  em- 
phasize distinctly  that  we  did  not,  at  this  time,  consider  our 
blood  culture  "5"  of  great  scientific  value  because  the  ascitic 
fluid  with  which  it  had  been  taken  had  not  been  sufficiently 
controlled  before  use. 

When  our  own  supplies  arrived  it  was  found  that  all  the 
ascitic  fluid  shipped  from  New  York  was  either  contaminated 
or  probably  because  of  aging  and  shaking  had  settled  out,  so 
that  its  specific  gravity  in  no  case  exceeded  1012.  However,  by 
this  time  (the  end  of  May)  cases  of  ascites  appeared  at  the  hos- 
pital, and  these  were  tapped.  From  two  cases,  ascitic  fluids 
"X"  and  '^Y"  were  obtained,  fluids  which  we  thought  more 
nearly  approximated  the  conditions  set  down  by  Plotz.  With 
these  fluids  a  number  of  blood  cultures  were  taken,  ^'X"  hav- 
ing been  well  tested  for  sterility.  In  some  blood  cultures  both 
fluids  were  used.  From  blood  culture  "5"  to  blood  culture 
''35"  no  repetition  of  the  diphtheroid  anaerobic  organism  was 
obtained;  a  majority  of  these  cultures  were  negative  when  the 
control  tubes  were  negative,  in  two  of  them  streptococci  were 
obtained,  and,  in  several  others,  large  Gram-positive  bacilli 
were  present,  which  were  taken  to  be  evidences  of  contamina- 
tion. It  may  be  said  that  all  blood  cultures  which  showed  any 
evidence  of  contamination  were  indiscriminately  thrown  out. 
It  should  also  be  stated  that  during  this  period  hardly  any  of 
the  cultures  could  be  taken  before  what  we  would  consider  at 


TYPHUS  IN  SERBIA  265 

least  the  eighth  or  ninth  day  of  the  disease,  and  most  cases 
were  older  than  this.  In  blood  cultures  "35"  and  "38,"  one 
of  which  (38)  had  developed  in  the  hospital,  early  blood  cul- 
tures were  obtained,  most  of  the  tubes  being  taken  with  ascitic 
fluid  "X."  In  one  tube  of  each  of  these  a  number  of  heavy 
colonies  containing  small  Gram-positive  diphtheroid  baciUi 
were  found,  but  these  diphtheroid  organisms  showed  great 
similarity  to  contaminating  diphtheroids  found  in  control 
tubes  with  one  of  the  other  ascitic  fluids.  These  colonies,  there- 
fore, were  not  considered  to  have  any  significance.  In  blood 
culture  "41,"  another  early  case  which  had  developed  in  the 
hospital,  the  blood  culture  was  taken  on  what  we  assumed  to 
be  the  third  or  fourth  day  of  the  disease.  In  this  case  ascitic 
fluids  "X"  and  "Y"  were  employed  in  different  tubes.  This 
blood  culture  was  taken  on  June  12.  By  the  twentieth  two  of 
the  tubes  taken  with  ascitic  fluid  "Y"  were  grossly  contami- 
nated. On  one  tube  with  "X"  ascitic  fluid  which  had  shown 
no  contaminations  in  controls,  a  suspicious  colony  appeared, 
which  showed  small  Gram-positive  bacilli,  which  were  trans- 
planted on  ascitic  agar  slants  in  Buchner  tubes  and  in  ascitic 
glucose  agar  stabs  in  Buchner  tubes.  Two  of  the  transplants 
grew.  This  culture,  in  the  original  appearance  of  the  colonies, 
in  the  appearance  of  the  transplants,  their  anaerobic  growth 
requirements,  and  their  morphology  and  staining  properties 
corresponded  to  the  Plotz  organism. 

We  may  briefly  summarize  the  results  of  something  over  forty 
blood  cultures  on  cases  of  unquestionable  typhus  by  stating 
that  only  two  of  these  showed  organisms  which  corresponded  to 
the  Plotz  bacillus.  Cultures  from  the  older  cases  showed  oc- 
casional streptococci  and  Gram-negative  bacilli,  as  did  many 
of  the  cultures  taken  from  recently  dead  bodies  at  autopsy,  and 
these  we  regarded  as  secondary  invaders.  Indeed,  we  obtained 
the  general  impression  that  secondary  bacterial  invasion  of  the 
blood  stream  was  not  uncommon  in  typhus  fever. 

It  did  not  seem  to  the  writer  that  his  own  experience  justified 
drawing  definite  conclusions  about  the  Plotz  bacillus.  His 
opinion  was  against  the  aetiological  significance  of  this  organ- 


266  REPORT  OF  BACTERIOLOGIST 

ism  because  of  the  rarity  with  which  it  had  been  found,  and 
because  of  the  fact  that  the  necessity  of  using  unfiltered  and 
unsterihzed  ascitic  fluid  in  these  cultures  made  it  impossible  to 
exclude  absolutely  that  the  organisms  had  originated  in  the 
ascitic  fluid  rather  than  in  the  case.  While  the  difficulty  under 
the  circumstances  of  adhering  accurately  to  the  criteria  set 
down  by  Plotz  for  the  cultivation  of  his  organism  did  not  per- 
mit the  writer  to  draw  definitely  negative  conclusions  concern- 
ing this  organism,  yet  he  felt  that  his  work  as  a  whole  was 
more  against  it  than  in  its  favor. 

The  laboratory  meanwhile  had  been,  we  consider,  well  or- 
ganized, and  it  had  been  possible  to  extend  its  facilities  to 
Dr.  Castellani,  who,  with  his  personal  assistant,  used  it  during 
this  period  to  make  large  quantities  of  cholera  and  typhoid 
vaccines  for  the  use  of  the  Commission  for  the  Serbian  army. 
Autopsies  had  been  done  on  typhus  cases  and  on  other 
cases  which  interested  the  various  physicians  at  the  hospital 
whether  or  not  typhus,  and  the  laboratory  was  made  as 
generally  useful  to  the  hospital  as  a  whole  as  was  possible  at 
the  time.  During  this  time  also  it  was  used  by  Dr.  Sellards 
in  the  pursuit  of  his  special  studies  until  his  departure  for 
Belgrade. 

Guinea  pig  work  was  necessarily  limited  since  three  guinea 
pigs  only  survived,  of  the  fifty  taken  from  New  York,  probably 
owing  to  the  rough  weather  and  cold  on  the  way  over,  which 
took  pretty  nearly  a  month,  with  many  changes  of  weather  and 
many  transshipments  en  route.  Five  further  guinea  pigs  were 
obtained  at  the  end  of  May  by  the  great  courtesy  of  Dr. 
Kopanaris,  sanitary  chief  of  Greek  Macedonia,  in  Salonika. 
Inoculations  into  these,  intraperitoneally,  of  blood  directly 
from  the  patient  were  made  immediately  after  arrival  at  the 
hospital,  and  one  of  these  after  twelve  days  showed  what  we 
considered  a  typical  rise  in  temperature.  A  transfer  from 
this  pig  to  another  resulted  in  a  temperature  suggestive  of 
typhus,  though  it  did  not  exceed  104°C.  at  any  time.  Trans- 
fers from  this  one  were  also  made,  but  showed  no  temperature 
reaction. 


TYPHUS  IN  SERBIA  267 

When  the  Kopanaris  pigs  arrived,  all  of  them  were  injected 
from  patients  at  various  times,  and  in  a  number  of  them  the 
peritoneal  cavity  was  punctured  by  the  Pfeiffer  method,  two, 
three,  and  six  days  after  inoculation  with  the  typhus  blood, 
and  cultures  and  smears  made  from  the  puncture  fluid.  In  one 
of  these  pigs  small  Gram-positive  bacilh  were  seen  on  the  third 
day  after  inoculation  with  typhus  blood.  Smears  of  this  pig 
were  studied  very  carefully,  both  by  the  writer  and  by  Dr.  Cas- 
tellani,  and  both  beheved  that  they  were  in  a  general  way 
similar  to  the  Plotz  organism,  but  none  of  the  other  pigs 
showed  such  organisms,  and  cultures  from  the  pigs  with  the 
materials  used  both  aerobically  anaerobically  were  entirely 
negative.  Two  of  the  pigs  were  injected  rather  a  short  time 
before  leaving  in  the  hope  that  the  virus  might  be  kept  going 
for  Dr.  Hopkins  on  his  arrival. 

Vaccination 

At  about  this  time  the  question  arose  whether  or  not  the 
Serbian  troops  should  be  vaccinated  with  the  Plotz  organism. 
The  question  was  put  to  the  bacteriologist  by  the  director, 
Dr.  Strong,  and,  as  may  be  easily  seen  from  the  above  report, 
the  writer  was  not  yet  in  a  position  at  this  time  to  either  con- 
firm or  deny  the  aetiological  importance  of  the  Plotz  organism. 
The  isolated  apparently  positive  findings  in  the  blood  cultures 
described  above  were  not  deemed  by  him  sufficient  basis  for 
advising  extensive  vaccination  which  would  subject  the  Ser- 
bian government  to  much  administrative  trouble,  to  expense, 
and  difficulties  of  mobihzation  at  a  time  of  critical  military 
necessities.  Moreover,  the  epidemic  was  distinctly  on  the 
wane  at  this  time,  the  decHne  being  progressively  more  rapid 
as  the  weather  turned  warmer.  The  writer,  therefore,  dis- 
tinctly advised  the  director  that  there  was  no  information  at 
his  disposal  at  this  time  to  justify  a  general  vaccination  of 
Serbian  troops  and  population.  This  statement  is  made  in 
order  to  make  clear  that  in  omitting  a  vaccination  order  at 
this  time  the  director  of  the  expedition  asked  the  advice  of  the 
writer  and  obtained  the  above  negative  reply. 


268  REPORT  OF  BACTERIOLOGIST 

The  writer  started  South  on  the  twenty-ninth  of  June  after 
turning  over  his  material  to  Dr.  Sellards  and  leaving  the  lab- 
oratory under  the  direction  of  Dr.  Castellani.  Dr.  Sellards 
took  charge  of  the  typhus  materials  and  the  culture  of  the 
supposed  Plotz  organism  isolated  from  the  case  above  de- 
scribed, which  he  turned  over  to  Dr.  Hopkins  who  came  over 
shortly  after  to  continue  the  work. 


PART  V 

SUPPLEMENTARY  BACTERIOLOGICAL  REPORT 

OF  THE  AMERICAN  RED  CROSS  SANITARY 

COMMISSION  TO  SERBIA 

By  J.  GARDNER  HOPKINS 

The  writer  left  New  York  on  the  steamship  Thessalonica  on 
June  19  and  arrived  at  Skoplje  on  July  19.  Typhus  had  been 
for  some  time  on  the  decrease,  and  by  this  time  there  were  very 
few  acute  cases  available  for  study.  On  arrival  at  Skoplje, 
however,  it  was  found  that  a  dozen  cases  from  the  civil  jail  at 
Cavadara  had  recently  been  brought  to  the  Sixth  Reserve 
(Lady  Paget)  Hospital,  five  of  which  were  in  the  acute  stage  of 
the  disease,  and  the  writer  proceeded  at  once  to  the  hospital  to 
study  these  cases.  He  found  there  a  well-equipped  bac- 
teriological laboratory,  which  had  been  organized  by  Dr.  Zins- 
ser and  his  coworkers,  which  was  then  being  used  by  Dr. 
Castellani  of  the  American  Commission  for  the  preparation  of 
typhoid,  paratyphoid,  and  cholera  vaccines  for  the  Serbian 
army.  There  were  two  Austrian  prisoners,  assigned  to  labora- 
torj^  duty,  whom  Dr.  Zinsser  had  trained  in  the  work.  The 
use  of  the  laboratory  was  put  entirely  at  the  disposal  of  the 
bacteriologist,  and  he  was  also  given  full  charge  of  the  typhus 
cases  through  the  courtesy  of  Dr.  Maitland,  the  chief  physician 
of  the  Lady  Paget  Hospital.  Cultures  were  made  from  one 
case  with  materials  at  hand  in  the  laboratory,  and  as  soon  as 
agar,  pleural  fluid,  and  blood  serum  could  be  prepared,  cul- 
tures were  taken  on  other  acute  cases.  Two  days  later  an  addi- 
tional case  in  the  acute  stage  of  the  disease  was  brought  in 
from  Cavadara. 

Blood  Culture  Studies 

Cultures  were  made  by  the  method  described  by  Plotz,  the 
blood  being  taken  from  the  arm  vein  with  a  sterilized  syringe, 
and  mixed  with  2  per  cent  glucose  agar,  to  which  ascitic  fluid  or 

269 


270      SUPPLEMENTARY  REPORT  OF  BACTERIOLOGIST 

human  blood  serum  was  added.  The  mixtures  were  made  in 
deep  tubes,  and  some  of  the  tubes  from  each  of  the  first  eight 
cultures  were  placed  in  Buchner  tubes  before  the  agar  had 
solidified.  Considerable  emphasis  has  been  laid  by  Plotz  on  the 
specific  gravity  of  the  ascitic  fluid  used  in  the  culture,  and  some 
difficulty  was  found  in  obtaining  fluid  which  answered  the  re- 
quirement, that  is,  in  which  the  specific  gravity  was  over  1015. 
The  only  fluids  available  at  the  hospital  were  those  obtained 
from  cases  of  pleurisy  with  effusion,  in  which  the  specific  grav- 
ity ranged  from  1011  to  1018.  In  one  culture  a  specimen  of 
ascitic  fluid  was  employed  which  had  been  kindly  furnished  by 
Dr.  Plotz  and  had  been  found  satisfactory  in  his  work  at  Mount 
Sinai  Hospital.  In  other  cultures  blood  serum  obtained  by 
venesection  in  cases  of  nephritis  was  used,  as  it  seemed  that 
this  must  have  all  the  advantages  of  a  specimen  of  ascitic  fluid 
with  high  protein  content.  Other  specimens  of  ascitic  fluid  of 
lower  specific  gravity  which  had  been  brought  from  New  York 
were  also  used. 

The  cases  from  which  the  cultures  were  made  were  all  con- 
sidered by  the  physicians  who  had  studied  the  typhus  epidemic 
in  Serbia  to  be  typical  cases  of  typhus.  They  had  high,  con- 
tinuous fever,  ranging  from  102°  to  105°  and  profuse  rash  ap- 
pearing, in  some  cases,  on  the  palms  of  the  hands.  The  cultures 
were  all  made  during  the  febrile  period,  from  the  seventh  to  the 
eighteenth  day  of  the  disease,  as  nearly  as  could  be  ascertained 
from  the  history. 

Twelve  cultures  in  all  were  taken  from  the  six  cases  available, 
and  were  observed  for  at  least  three  weeks'  incubation.  The 
tubes  before  being  discarded  were  emptied  into  sterile  Petri 
dishes  and  the  cylinder  of  agar  cut  into  thin  slices  in  order  to 
detect  any  small  colonies  which  might  have  escaped  observa- 
tion in  the  rather  opaque  medium.  A  number  of  tubes  showed 
surface  contaminations,  due  probably  to  the  fact  that  the  wards 
in  the  hospital  were  exceedingly  drafty  and  it  was  impossible 
to  avoid  occasional  contaminations  from  dust.  In  only  one  in- 
stance, however,  was  a  deep  growth  obtained  which  in  any  way 
resembled  the  organism  described  by  Dr.  Plotz. 


TYPHUS  IN  SERBIA  271 

This  one  positive  culture,  No.  10,  was  obtained  on  the 
fifteenth  day  of  the  disease  from  a  patient  who  died  the  follow- 
ing night.  The  temperature  at  the  time  of  the  blood  culture 
was  102°.  Two  tubes  from  this  culture  showed  each  a  single 
large  colony  in  the  depth  of  the  medium,  which  appeared  after 
ten  days  of  incubation.  The  colonies  were  surrounded  by  a 
zone  of  precipitated  albumen  and  showed  morphologically 
srnall  Gram-positive  bacilli,  strongly  resembling  those  in  the 
culture  which  had  been  furnished  by  Dr.  Plotz.  On  subculture 
the  organism  proved  to  be  an  obligate  anaerobe,  until  it  had 
been  preserved  on  artificial  media  for  nearly  two  months,  after 
which  very  faint  growth  in  aerobic  cultures  was  obtained. 
Like  the  Plotz  organism  it  rapidly  produces  acid  in  glucose 
serum  media  as  shown  by  the  precipitation  of  the  protein.  It 
grows  somewhat  more  heavily  than  the  cultures  of  Dr.  Plotz 
which  the  writer  has  seen,  and  produces  deep  yellow  pigment, 
at  times  with  a  pinkish  tinge.  Inoculation  of  the  culture  in  the 
third  generation  into  a  guinea  pig  was  without  result.  Since 
this  organism  showed  no  pathogenicity,  did  not  give  the 
agglutination  reaction  described  by  Plotz  and  Olitsky,  and 
resembled  organisms  described  by  Torrey  as  occurring  as  sapro- 
phytes in  pathological  lymph-nodes,  it  could  not  be  regarded 
as  significant. 

Agglutination  Studies 

As  the  patient  from  whom  the  culture  was  obtained  died 
before  recovery  of  the  bacillus,  it  was  impossible  to  test  the 
organism  against  his  own  serum.  Macroscopic  and  micro- 
scopic agglutination  tests  were,  however,  carried  out  with  the 
serum  of  convalescent  typhus  cases  in  the  hospital  which  had 
had  a  normal  temperature  for  a  period  of  ten  days  to  several 
weeks.  Later,  on  going  to  Nish,  a  case  was  found  which  had 
had  a  normal  temperature  for  only  five  days,  and  serum  ob- 
tained through  the  courtesy  of  the  Russian  Red  Cross  phy- 
sician in  charge  was  also  tested  against  the  organism  in 
question.  None  of  the  typhus  sera  gave  definite  agglutination 
in  excess  of  that  obtained  in  normal  controls. 


272      SUPPLEMENTARY  REPORT  OF  BACTERIOLOGIST 

Autopsies 

Autopsies  were  performed  on  three  cases  of  typhus  that  died 
during  the  febrile  period.  Cultures  made  from  the  spleen  were 
negative  except  for  post-mortem  contaminations. 

Guinea  Pig  Inoculations 

Two  guinea  pigs  were  inoculated  from  acute  cases  in  the 
Lady  Paget  Hospital,  and  one  from  an  emulsion  of  spleen  of  a 
typhus  case  obtained  at  autopsy,  but  no  typical  reactions  were 
obtained. 

Later  Cases 

As  no  further  cases  of  typhus  were  available  at  the  Sixth 
Reserve  Hospital,  attempts  were  made  to  locate  cases  suitable 
for  study  in  other  parts  of  the  country.  On  a  rumor  that  cases 
were  developing  in  GaHcnik,  on  the  Albanian  frontier,  a  trip 
was  made  to  this  place  with  a  bacteriological  outfit  in  the  hope 
of  obtaining  specimens,  but  the  rumor  turned  out  to  be  false. 
Later  two  cases  were  located  at  Mladinowatz.  These  were 
mild  cases,  and  were  seen  in  conjunction  with  Dr.  Sellards, 
Dr.  Baehr,  and  Dr.  Plotz.  Dr.  Baehr  and  Dr.  Plotz  made  cul- 
tures from  these  cases,  and  Dr.  Sellards  and  the  bacteriologist 
inoculated  a  monkey  and  four  guinea  pigs,  all  of  which  failed  to 
react.  Other  guinea  pigs  injected  from  these  animals  at  a  time 
when  reaction  might  have  been  expected  also  failed  to  show 
any  characteristic  rise  of  temperature.  Two  cases  of  probable 
typhus  were  also  visited  at  the  Serbian  military  hospital  at 
Ralja.  Blood  cultures  taken  from  these  cases  were  negative. 
Although  they  were  considered  typhus  by  the  physician  in 
charge,  they  were  certainly  not  outspoken  cases. 

Results 

Of  six  outspoken  cases  of  typhus  studied  in  the  acute  stage, 
all  gave  negative  blood  cultures  except  one.  From  this  an 
organism  resembling  the  Plotz  bacillus  was  obtained,  but,  as 
it  failed  to  agglutinate  in  serum  of  typhus  patients  and  failed 


TYPHUS  IN  SERBIA  273 

to  produce  any  typical  reaction  in  a  guinea  pig,  it  was  dis- 
carded. The  results  of  these  studies  were  not  conclusive  on 
account  of  the  few  cases  available  for  study.  However,  the 
failure  to  isolate  an  organism  corresponding  to  that  described 
by  Plotz,  from  the  typical  cases  studied,  has  a  certain  value  as 
negative  evidence.  While  these  experiments  are  too  limited  to 
be  considered  as  disproving  the  reports  of  Plotz  and  his  cowork- 
ers as  to  the  aetiology  of  typhus,  they  failed  to  confirm  these 
results,  and  the  writer  so  reported  to  the  chief  of  the  commis- 
sion, Dr.  Strong. 

As  there  seemed  little  likelihood  of  obtaining  further  suitable 
material  for  study,  the  writer  left  Serbia  on  the  fifteenth  of 
September. 

In  conclusion,  acknowledgment  should  be  made  of  the 
hospitality  and  courtesy  extended  by  Lady  Paget 's  British 
unit  in  charge  of  the  Sixth  Reserve  Hospital  and  the  invariable 
courtesy  of  the  Serbian  physicians  and  officials. 


PRINTED   AT 

THE    HABVARD    UNIVERSITY    PRESS 

GAMBHIDGE,  MASS.,  TJ.  S.  A. 


DATE  DUE 

-    ■'    '' 

MAR  27 

'm^ 

f.»rL.CF,o 

PHINTEO  IN  US    A 

BOSTON  COLLEGE 


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